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SK SHIP# 232535530 IIIIIIIINI�IIII'I'IIIIIIIIIIIIIIIII� <br /> 0 0 7 7 6 9 8 6 8 S K S <br /> Please print or type. Form Approved.OMB No.2050 0189 <br /> UNIFORM HAZARDOUS 1.Generator ID Number _ 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAI 0U 007769868 SKS <br /> 5 Generator's Name and MadirgAddress Generator's Site Address if different than mailing address) <br /> r719 <br /> .;arlan Rd <br /> !?Op CA 95330-98k:.` <br /> Generator's Phone: 209-274-1895 <br /> 6.Transputer 1 CompanyName INC U.S.EPA ID Number -1,00008! <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEANHARHORS OF BUTTONWILLOW U.S.EPA ID Number <br /> 2.500 L-OKERN ROAD <br /> HLITTONWILLOW CA 33206 <br /> 661-762-6200 CRD990675276 <br /> Facility's Phone: <br /> 9a. 91,.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10.Cgrllekmers ti.Total 12.Unit 13 Waste Codes <br /> HM end Packing Group any)) No Tmpe Quantity WLNoI. <br /> K <br /> 150 P I a I <br /> Liu <br /> Z <br /> w - <br /> 4. <br /> 14,Special Handling Instmcboue and AddiOonal Information SD:BL <br /> �U Sb � <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desclbed above by the proper shipping name,aware classified.packaged. <br /> marked and Iabeleclplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expel shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I cerbfy that the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity generator) )(dl am a small quantity generator)is true. <br /> Generatpe.alOfl roe. rinted7ryped a Signatu Month Day Year <br /> e �� <br /> 16 International Shipments <br /> FElthroat to U.S. Ej Export from U.S. ort of entrylezit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> C 17.Transporter A wledgment of Receipt of Materials <br /> LJ <br /> Transporter 1 P- ted7ry d Name Signature Month Day Year <br /> a <br /> 111 �: 0 <br /> z Transpo`�r 2 PnnledRyped Name gn re Month Day Year <br /> 1 10 1c)r Ito <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 1 Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> x-d <br /> LL Fadliys Phone: <br /> W 18c.Sm igmdu of Alternate Facility for Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardou Waste Report Managenlenl MetlaO Codes(i.e.,codes for hazardous waste veaMenL disposal,and recycling systems) <br /> 2' 3 4. <br /> 20.Dei adlity Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 11 Pen SignaNre Monty Day <br /> v ad' <br /> EPA Form 870D-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA'S e-MANIFEST SYSTEM <br /> 1)73612571405` <br />