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GSI. SK SHIP# 230033583 IIINI11111111sill III III III <br /> 007312347SKS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2. ge o 3.Emer n R s se P n 4.Manifest Tracking Number <br /> WASTE MANIFEST CALO00394668 1215"��-1"°r�a 007312347 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> O' Reilly # 4719 <br /> 15079 S Harlan Rd <br /> L-�THROP CA 95330-9802 <br /> Generators Phone: 209-234-1895 <br /> 6.Tran rt r 1 Compan ame - U.S.EPA ID Number <br /> S�EgTY-F,L�EN SYSTEMS INC TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD, <br /> Facility's Phone: SAN JOSE CA 95133 <br /> 408-441-0962 CAD059494310 <br /> 9a 96.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.Nol. <br /> pill X 1RQ UN1993, WASTE FLAMMABLE LIQUIDS DM G F001 F00'2 F003 <br /> 0 N.6. 9, (XYLENES, BENZENE), 3, PG 11 <br /> qQ D001) I 'S� F005 D001 873 <br /> w <br /> Z <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 8170.4389 OR161.76 � CSG: <br /> DERE#18 Ei <br /> c'4H EMERG�NCY#800-468-1760-CH/SK/TFI-Contract t�etain 5' genera tUr c�d'n�}11 15 enc authori y <br /> n P a^ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Polly and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplararded,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 cerfily that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of sent. <br /> I sadly that the waste minimiution statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b if I am a small quantity g erator)is We. <br /> fferors Pnntedlfyped Name Signature Month Day Year <br /> � I I <br /> 16.International Shipments <br /> p_ ❑Import to US. ❑Export from U.S. on of entry/exit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> lac <br /> 1 Pnnted(lyped Nam gnature - Month �Day Year <br /> aca <br /> Q T erg Pnnted rFype ame Month Day Year <br /> F <br /> t1 screpancy <br /> 18a.Discrepancy Indication Space ❑ Qcmlity ❑T ❑Residue ❑Partial Rejection YPe j El Full Rejection <br /> - i <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone'. <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3, 4. <br /> le <br /> 20.Designated Facility Ow er or Operator:Cedification of receipt of h ous materials covered by the manifest except a ed in Item 1 <br /> illl Printedlfy Name Signature Month Iky yea <br /> EPA <br /> Form 58772009-247 12-17) Previous editions a soete. DESG EDFA TO EPA's e- ANIFEST SYSTEM 9'874301 _ <br />