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SSL SK SHIP# 2369556.4 IIIiiI E11lil �Ilil l li li�l ii I Edi <br /> 008343611 SKS <br /> Please print or type- s Forth Approved-OMB No.2050-0639 <br /> UNIFORM HAZARDOUS 1.Genn"ID Number c00494 72 2 P 1 of E 4.Manffest Tfacki3 611 SKS <br /> Number <br /> 0 0 8 3 <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> G' Reiilyy #t 3811 qm <br /> 1950 McHenry, five <br /> ESLAL.UN LA 95320--'c Dal <br /> Generator's Phone: 209-638-6384 <br /> s.�Trr prier t cn IlameSY6'�'ES INC U-S-EPA ID Number ix k0�llI1`�'Ib <br /> 7-Transpurterl 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SYL INC. INAD039 322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARIBURS GRASSY MOUNTAIN U-S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NURIH KNOLLS EX1'1' 41, OFF 1--130 <br /> KNOLLS , �r 84083431#4-431 uI3i613tbi T4b '� <br /> Facility's Phone: <br /> 9a 9b-U.S.DOT Description[including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group If any)) 13.Waste Codes <br /> NO, Type Quantity Wt.Nd. <br /> 1.14 NON-RCRO HAZAROIJUS WASTE, SOLID, DM P 161 e <br /> a a tASSURBEN•T AND OIL), 001 too <br /> z 2, <br /> w <br /> c� <br /> 3. <br /> ■ <br /> 7A <br /> 4. <br /> a <br /> 14.Special Handling Instructions and Additional Inlomrafion r SD:Gid 868141 X38 UR 12256 CSG: e. <br /> -to 3�D_3 3 3 <br /> 24N retained by generator confers agency authority <br /> on Initial transport er to add or substitute add itionaI transport ers an generat or' s Deha If <br /> 15. GEN ERATOR'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 /> h.r marked and labeled/placarded,and are in all respects in proper condition far transport according to applicable international and national governmental regulations.t ex <br /> Exporter,I certify that the contents of this oertsignment conform to the terms of the attached EPAAcknowledgment of Consent. P�shipment and I am the Primary <br /> I certify that the waste minimization statement identified in 40 CFR 262-27(a)(d I am a large quant ty generalor)or[b)(90m a. quantity generator)is true- <br /> GeneratorsK*emes PnnteaTyped Name Signature Month Day year <br /> I 49�= I V <br /> j 16.International Shipments <br /> prL Import to U.S. ❑Export from U.S. Port of entrylexit. k` <br /> x Transporter signature(for exports only): Dale Leaving U.S.: <br /> fY 17.Transporter Acknowledgment of ReoW of Wriiii ials 19 <br /> w <br /> Transporter 1 Printedfryped Name Signaturh Mqh Day F Year <br /> CL <br /> M Tran 2 Print yped Name Sgnahrre Month Day Year <br /> A�►^ � s S Jr 7l <br /> 18-Discrepancy <br /> 18a-Discrepancy Indication Space <br /> i•,fr ❑ Quantity ❑Type ❑ReSiduB ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Atemate Facility(or Generator) U-S.EPA ID Number <br /> J_ <br /> V <br /> Fabfitys Phone: <br /> W 18c.Signature of Afternate F&Aty(or Generator) F. FAonth Day Year <br /> a <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste[reatmerht,disposal,and recycling systems) <br /> LU Q 1 1�1 is" "' 2. 3, . 4. <br /> 20.Designated Facility Owner or Operalor:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Prin Ryd N 5 atone Month Da Year <br /> I Zz <br /> 1]1 190.53%5��-. -roths editions are obsolete- DESIGNATED FAM [TY 0 EPA's e-MANIFEST SYSTEM <br />