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SSL SK SW*'2i2I!6W <br /> Form Approved.OMB No.205N039 <br /> Please print or type. r 2 Pa 1of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.(�9neramrlD Nuer SKS <br /> CAL 429472 1 1-800-468-1760 v <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address in diberem than mailing--- <br /> O' Reilly N 3811 <br /> 1950 McHenry Ave <br /> ESCALON CA 95320-2081 <br /> Generators Phone: 209-838-6384 U.S.EPA ID Number <br /> s.Transporter I Company Name T X R0000B 1205 <br /> SAFETY-KLEEN SYSTEMS INC <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name MAD039322250 - <br /> CLEAN HARBORS ENV SVC INC. <br /> U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE <br /> �Ali 1021JOSE <br /> BERRYESSA ROAD CA 85133 <br /> 408-441-0962 <br /> CAD059494310 <br /> Fadlity's Phone: <br /> ge 9b.U.S.DOT Description(induiling Proper Shipping Name,Hazard Class,ID Number, No Containers Qu Total 12.Unit 13.Waste Codes <br /> ,NM and Packing Group(if any)) N¢, Type Quantity Wt.N01. <br /> NON-RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> K (ABS RBENT AND OIL),--Nf'A- p a S <br /> 4a <br /> i 2. <br /> _. 3. <br /> �l <br /> i <br /> 4 <br /> 14.Special Handling Instructions and Addibonal Information TSD:SJ 82522541 DR12256� QAC 1,r7 <br /> 24H EMERSENCYi800-468-1760-CH/SK/TFI-Contract retained by generator confers a ency authori y <br /> -on-GENERATOR'SIOFFEROR'S CE 71FN:ATION: I hereby deGare that the contents of this consignment are fully and acwrately described hove by the proper shippi g name,and are classified,Packaged. <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I cenity that the contents of this consignment conform to the terms of Use attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimiution statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(fi am a small quantity generator)is true. Month Day Year <br /> G ra rslOfferors Prinled(fyName Sig to <br /> l Gt"�bY r o 3 a 3 2 a <br /> It.InternationalShipments ❑Import to LLS. ❑Export from U.S. Port of entrylexit. <br /> Date leaving U.S.: <br /> ? Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials Month Day- Year <br /> K Tra rter 1 PrintedRYear <br /> ypeQName Signature 0� ^3 <br /> 1 O G�; <br /> IL Mpnth Day <br /> z ns r2 Pit lfypd Na igna re <br /> ( C / U . <br /> c C a'1 <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ puanfity ❑Type Residue ❑PartialRejection Full Rejection <br /> . Mandest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Fadllty(or Generator) <br /> J <br /> U <br /> LL Facility's Phone: Month Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> 22 Q <br /> Z <br /> 19,Hazallous Waste Report Management Method Codes(i.e.,codes for hazartlous waste treatment,disposal,and recycling systems) 4 <br /> 3. <br /> Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except peed in Item 18a MMonth year <br /> 1120. <br /> rintedlfyppkNarae � � Signature � 7/1V^ID <br /> EPA Form 87Oj�0�2J2`r( .12-17) Prevwus editions are obsolete. <br /> DESI AT D FACILITY 1'.O GENERATOR <br /> 1)7361257/40559605 <br /> ----------------- <br />