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'S;L SK SHIP# 232414094 <br /> 0077715048 KS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number C`AL000429472 2.Pa 1 of 3. m s ,0 4.Manifest Trackin Number <br /> 9� - g� 007711504 SKS <br /> WASTE MANIFEST <br /> 5.Gu r3(oes1N�rge and MailtLgAddiess Generator's Site Address(if different than mailing address) <br /> 1950 McHenry Ave <br /> ESCAL..ON CA 95320-2081 <br /> Generators Phone: 209-838-6384 <br /> 6.Tr M ftY' onRE SYSTEMS INC U.S.EPA ID Number T X R000081205 <br /> 7.Transporter 2 Com an Name U.S.EPA ID Number <br /> CLEAN H1RDR5 ENV SVC INC. MADO 93�2c50 <br /> 8.Designated Facility Name and Site Address CLEANHARBO RS OF BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-6200CAD980675276 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> Ir 1. 1 ON-RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> O tABSJRPENT AND OIL), <br /> z 2. <br /> Lu <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Addibonal Information TSD;BL 84201 105 OR 12256 CSG <br /> a)au <br /> 24H EMERGENCY#800-468-1780-CH/SK/TFI-Contract retained by generator confers agency authori y <br /> on initial transporter to add or substitute additional transporters on generator' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Gene tor'slOfferors Printedrryped Name Sig ature Month Day Year <br /> pro u 0.2 GAS <br /> 16.International Shipments <br /> ❑Import to U.S. El Export from U.S. Po f ent exit: <br /> ? Transporter signature(for exports only): Date ee U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> � Tr porter 1 Printed(fype ame pnatur Month Day Year <br /> O <br /> CL <br /> U) Transporter 2 Printed/Typed Name u e Month Day Year <br /> O Oel Z'-/ I Zo <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp <br /> 1:1T e El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> tai Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N19.Hazardous aste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. / J 2. T- <br /> 20. <br /> Designat F ility Owner or Operator:Certification o ceipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrra ame Signature Month Day Year <br /> EPA 1F 671 ,' gv 6� g4rrNvus editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1 J t,:� 3 /�# J J <br />