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SSL SFS SHIP# 236587039 <br /> 0a8315332SKS <br /> Please print or type. Form Approved,0 M B No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator IQ Number, CAL'�ld04 947 2 Pae 1 of .Er cy s�ns�P 4. a e Tr kI m r �� <br /> . WASTE MANIFEST - lJ J�g 32 <br /> 5-rte, ratol,,pNre and Mai A dress Generator's Site Address(d different than mailing address) <br /> ❑'�2e i 1�y ii �3�1� <br /> 1950 McHenry Ave <br /> ESCALON CA 95320-2081 <br /> Generator's Phone' <br /> 209-193E-6384 ' <br /> "99FtT r-�SYSTEMS INCU-5.EPA ID Number TX R@00081205 <br /> T.Tran�ter 2r�a n Name U.S.EPA ID Number <br /> CLAN FiRRI AS ENV SVC INC, MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA IQ Number <br /> 4- 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, LIFE I-80 <br /> KNOLLS , LET $4033 <br /> 435-884-8915 UTD"1301748 <br /> Fad qs Phone: <br /> ga 9b-U-S-DDT Desuipdon(including Proper Shipping Name,Hazard Class,ID Number, 10-Containers 11.Total 12-Unit <br /> HM and Packing Group(it airy)) 13.Wade Codes <br /> No- Type Quantity WI.Nd. <br /> 1,NONENUN—RCRA HALARDOUS WASTE, SOLID, DM P 181 <br /> F [ABSbRHENT AND OIL), N/A <br /> x 2. <br /> w <br /> c� <br /> t. <br /> s <br /> 3. <br />{ <br /> 4 <br /> aY <br /> 14.Special Handling Instructions and Additwnal Information T SD p GM 86488982 OR 12256 L'SG <br /> l � <br /> 24H EMERGENCY#800-468-1760-CH/SK/I•FI Contract retained by generator confers agency authorit <br /> on initial transporter to add or substitute additional transporters an generator's behalf. <br /> 15- GENERATOR'SiOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desaibed above by the proper shipping name,and are classified,padkagad, { <br /> marked and IabefedrpW&ded,and are in al respects in proper condition for transport according to appicable international and national governmental regulations.If export shipment end I am the Primary <br /> Exporter,t certify that the contents of this oonsoment conform to the terms of the attached EPAAd owledgnhent of Consent <br /> f certify Oral the waste minimization statement identified in 40 CFR 262-27(a)(d 1 am a large quantity generator)or(b)(dl am a smart quantity generator)is hue. q6 <br /> ensldtemes PnniediTyped Name Sgnalure MonthDay Year <br /> ■ <br /> 16.International Shipmen11 <br /> F � IF ❑Import to U.S. ❑Export Tram U.S- Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> c 17.Transporter Ad now Wrient of Receipt of Materials <br /> LL1Transporter 7 PrintAedf`Typed Name ^ Signature Morithh Day Year <br /> aranspon 2 Prin yped Mame Signature <br /> o� Month Day Year <br /> 3 IIJ R- <br /> 1 B. <br /> 19.Discrepancy 4 <br /> 18a-Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 6-A <br /> Manifest Reference Number- <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> tai Facility's Phone: <br /> W 18c.Signature ofAltemate Facility lar Generator) s Month Day Year <br /> • a <br /> rn 19-Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste healment,disposal,and recycling systems) <br /> l u' p 2. � 3. 4- <br /> H � � <br />` 20.Designated Facility Owner or Operator,CeVQbon of receipt of hazardous materials covered by the manifest except as rated in Item 18a <br /> i <br /> Pan y Nar sig�re Month Dao Year <br /> -)AA� EI(A� r U I 2Z <br /> Ey�%yg�374bj A!rous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />