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SSL SK SHIP# 230358222 IIINil1IN1101111111111 <br /> 0072762695KS <br /> Please print or type. - Form Approved.OMB No.2050-0039 - <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2. g of 3.Eme[g g R gge Ph € 4.Manrfest Tracking Number <br /> WASTE MANIFEST CAL000394668 1—t51[rrA— bli—l�b@ 007276268 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Vr`�l <br /> O' Reilly # 4719 <br /> 15079 S Harlan Rd <br /> LATHROP CA 95330—W02 <br /> Generators Phone: 209-234-1895 <br /> 6.TraSn40TYmpAnyNffme SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD03932225@ <br /> 8,Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> CRD059494310 <br /> 408-441-096^c <br /> Facility's Phone: <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group('rfani No. Type Quantity Wt.Nol. <br /> NON—RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> o ABSaRBENT AND OIL), <br /> z 2. <br /> W <br /> r7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional lnforrnatior ''.T •SJ 82050086 ORI-6176 CSG: <br /> 24H EMERSFNCY#800-468-1760—CH/SK/TFI—Cant ract retain by generator canfgrs a encsy a he y <br /> 15. GEgn R' 1OFFERORTRIIIIIIIIIINWIlerAydeclare that the contents of this consignment are Polly and accurately described above by the proper shipping name,and areclassified,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 1 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 /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genera (b)(it I am a small quantity generator)is we. <br /> rocs 1 5(' p¢4yped Name N Month Day Year <br /> 4 b1� ► 7 zA <br /> 16.International Shipments <br /> F '171Import to U.S. El Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TmnsporterAcknowledgmentof Receiptof Matertals 1 <br /> 1— T iter1 Printed4typed me atureMonth Day Year <br /> Q� Ul ! `IO <br /> aZ renspoder2 P tetl/T Nam I Signa ure �y - Month Day Year <br /> F 1 t L �.l ctA <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manliest Reference Number: <br /> r 18b.Alternate Fa0bly(or Generator) U.S.EPA Number <br /> J <br /> V <br /> LL Facility's Phone' <br /> ou 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> an <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes far hazardous waste treatment,disposal,and recycling systems) <br /> 1, / 2. 3. 4. <br /> 20.Designated Facility Ow r or Operator Certification of receipt of hazardowernaterals covered by the manifest=t as noted in Ite <br /> Printedfrypea me Signatu Month Day Y <br /> ng <br /> EPA Form 8700-22 Rev.12-17 Previous edifions are ob ete. DESIG TED ITY T s e-MANI EST SYSTEM <br /> 1)736 9605 <br />