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SSL SK SHIP# 231397499 II�II�I�IIIIII�IIIIJII�( 55 (KK�ISsIII) <br /> Please print or type. 0 C 7 yForm Approved.OM6 No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2. age 3. me R e P 4.Manifest Tracking Number <br /> CAI_00039466 3 � � - '� 1007461666 $KS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Genemtots Site Address indifferent than mailing address) <br /> O'Reilly # 4719 <br /> 15079 S Harlan Rd <br /> s.Tf!�'rrT` CA 95.530-9$02 <br /> Generator's Phone: '-'�9-;=.:'S4-1895 <br /> 6.Tr�sonrter�,Gompan_u" .9YSTEMS INC U.S.EPA ID Number TX,R000081205 <br /> 7.Tran(s�p�ort`e-r 2 Company <br /> Name U.S.EPA ID Number <br /> CI . . <br /> _FAN 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 /> SAN JOSE CA 95133 <br /> 408-441-0952 ' CADO.`',94'34-:10 <br /> Facility's Phone: <br /> 9y, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> aril roup(Aany)) 13.Waste Code <br /> No. Type Quantity Wt./Vol. <br /> NON-BARD HAZARDOUS WASTSOLIDt / DN /60 p 1g1 <br /> o ...AHSRB=NT AND OIL? , <br /> r`it!`ID{�^, <br /> z 2. <br /> w <br /> t7 <br /> 3. j <br /> r <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD.SJ 831,50931 OR1E:176r <br /> csc; <br /> a 13 <br /> 24H EMERGENCY#800-458-1750-CHlSK./TFI-Contract retain :nerator r fern ag ncy a+.)Ori _v <br /> on initial transporter to add or substitute additions trans orters nn venerator' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of Nis consignment are fully and accurately described above by the proper shipping name,and are classified,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 I 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 /> I certify that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generetors/Ofieror's Pnnted/ryped Name Signi Month Day Year <br /> !7A T'r IsS i <br /> J6. infamatiorial Shipments <br /> 2 ❑Import 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.Transporter Acknowledgment of Receipt M Materials <br /> a Tporter 1 Prineame Si natuO <br /> Month Day YearRt is- III <br /> b <br /> z IraiMporter 2 Pnnted/ryped Name Si nature <br /> 9 - Month Day Year <br /> 9 <br /> } 18.Discrepancy 1 <br /> 18a.Discrepancy Indication Space <br /> ElQuantity ❑Type El Residue ElPartialRejection El Full Rejection <br /> > Manifest Reference Number' <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitya Phone' <br /> 18c.Signature of Alternate Facility(or Generator) <br /> F Month Day Year <br /> z <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3. 4, <br /> elyz <br /> i <br /> 1 <br /> 20.Designated Facility Owner or perator:Certification of receipt of hi materials covered the mannest axe <br /> P&Snded in Ite <br /> Printed/Typed Name Signs Month Da Year <br /> r <br /> EPA Form 87OO-22LRev.12-17) Previous edifins obsolete. D IGNATE ACILITYTO EPA's e-MANIFEST SYSTEM ; <br /> i !73 F.1. 405`,9605 <br />