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SK SHIP# 233161098 II i I) III I11 I(I'I�)I III II(II)�II�III <br /> 0 0 7 7 6 8 7 4 3 S K 8 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number rALO00394668 J1.Page;lof 3.Emef R11Se RhonC,? 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> 1007768748 SKS <br /> 5.Gfn�r r'sNanr and ailipq�{� ss Generator's Site Address(if different than mailing address) <br /> U ttC'1 11 V <br /> 15079 S Harlan Rd <br /> LATHROP CA 95330-9802 <br /> Generator's Phone: 209-2234-1895 <br /> s.Tr 'fSYSTEMS INC U.S.EPA ID Number 7 X R000081 x'05 <br /> 7.Trpnsp,Q* C4mpanyrpe` "hIl! U.S.EPA ID Number MAD039.522250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONWILLOW U.S.EPA ID Number <br /> 2:500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-6POO CAD980675276 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if13.Waste Codes <br /> f )any)) No. Type Quantity Wt.Nol. p <br /> ASTE, SOLID, <br /> o (!SBS RBENT AND OIL), ESQ <br /> z 2. <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD BL 85071091 Oft 16176 <br /> ob 15 <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generaTo I COnfer:� agenC'yVQ�kthor' v <br /> an initial transporter to add or substitute additional transporters on generator' s behalf, <br /> 15. GENERATOR'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 /> 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 identified 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 /> Generators/Offeror's Pr i ted[Typed Name Signature _ Month Day Year <br /> VJ <br /> lC.�-Ire l 2� ZU <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U-91-1, <br /> . Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Pri d[Typed Name Signature Month Day Year <br /> 0- f� <br /> Z Transpo-rr9-r2Pr1tTM1ypeoName Sigure <br /> Month Day Year <br /> 21 <br /> e j L Zv <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type 1:1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) MonthDay Year <br /> Q <br /> Z <br /> U) 19.Haz rdous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. �3 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest pxcept a oted ig4tem 18a <br /> ri d ed Nam Signat a Month Day Year <br /> i <br /> EPA Form 6 QQ .{Rev.12, 7j.Q!�vious editions are obsolete. DESIGNATED FACILI Y TO EPA's e•MANIFEST SYSTEM <br />