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SSL SK SHIP# 229744175 11111R} IOW I <br /> Please print or type. 0 0 7 31111 3 1 7 1 S K S <br /> Form Approved.OMB No.2050-0)39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. R s e 4.Mao t Tracking Number <br /> WASTE MANIFEST CAL080394668 ' - 0 0 0 7 313171 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address tiPditferent Man running address) <br /> { i2silly # 4719 <br /> 179 S Harlan Rd <br /> LATHROP CA 95330-9882 <br /> Generator's Phone: 209-234-1895 <br /> 6.TtypemMo.i,Gorrylgn�.Nam¢ SYSTEMS INC U.S.EPA ID Number TX 8000081205 <br /> 7.Transporter�2 Company NatlmNe U.S.EPA ID Number <br /> CLEAN RBORS ENV SVC INC. MAD039 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ARAGONITE LLC U.S.EPA ID Number <br /> 11600 NORTH APTUS ROAD ' <br /> 435-884-8100 ARAGONITE , UT 84829 <br /> Facility's Phone: UTD981552177 <br /> 9a, 91h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Canis em 11.Total 12.Unit <br /> HM and Packing Group(rf any)) 13.Waste Codes <br /> No. Type Quantity WtJWT. <br /> a X 1. RQ UN1993 WASTE FLAMMABLE LIQUIDS DM P F001 FI01000 <br /> 2 F3 <br /> N.b.S. , (XYLENES, BENZENE), 3, PG Il <br /> 4: (DO01) 17r+ F0 Q 1 223 <br /> W. 2. <br /> LLI <br /> C'I <br /> A. <br /> 3. <br /> 4. <br /> 14,Special Handling Instructors and Additional Information -ISD•.AG 81 3538 OR16176 / CSG: <br /> i)ERG#128• _ _ _ ! `0533 g�g �v <br /> onHiniittial transporterlto0addfor7substitute additional transnarters DnnfeneratOrls behalf, y. <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arcJ are classified,packaged, _ <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national gm ermiental regulations.If export shipment and I am Me Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified M 40 CFR 262.27(a)(g I am a large quantity generator)a(b)(if I am a small quantity generator)is true. IV <br /> /Offeror\Pn'ntedRypetl Na �� - Signahxe Monts Day Yaar <br /> In.International Shipments YL'�" fO <br /> (_ <br /> 11 Import to U.S. ❑Export from U.S. Ponofenglledt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> r�Y 17.Transporter Aclawwledgment of Receipt of Materials <br /> I� 1 Pdnted/TypedNa re Month Day Year <br /> 0 1 / <br /> Vllrflner 2 Prince Signa urs Math Day year <br /> ..e ' r'i1S, 2. 'll <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fun Rejection <br /> Manifest Reference Number: ', <br /> 18b.Alternate Facility(or Generator) U.S.E-PA(D N <br /> L6 facililys Phone: <br /> 18c.Signature ofAnernaw Facility(or Generator) Month Day year <br /> y19.Hazardous Waste ReportManagement Method Codes(i.e.,codes fa hazardous waste treatment,disposal,and recycling systems) 4 <br /> C f t IV� 0 2. 3. <br /> 20.Designated Facility Omer a Operator.Certification of receipt of hazardous materials covered by the manifest except aspoked in nem 188 <br /> Pnnt1d11PMtM ecu Monts Veer <br /> Mtj <br /> EPS.F)g7$D ,�i�ev -t� Pe�yj�us editions are obsolete. ;p.. D E SIGNATED FACILITY TO EPA's 9-MANIFEST SYSTEM <br /> s <br />