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SSL SK SHIP# 231906558 Hill 1111111111111 <br /> 0073136448KS <br /> phase print or type. Form Approved.OMB No.2050-0059 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL000392916 2.Paijo j of3.E® R s e P,hone� 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 1lb 007313649 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> O' Reilly # 3501 <br /> 515 E Yosemite Ave <br /> MANTECA CA 95336-5837 <br /> Generator's Phone: 209-239-4188 <br /> 8.1W1-Cso SYSTEMS INCU.S.EPA ID Number TXROOM1205 <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 ARAGONITE, LLC U.S.EPA ID Number <br /> 11600 NORTH APTUS ROAD <br /> ARAGONITE , UT 84029 <br /> UTD981552177 <br /> 435-884-81 <br /> Fadlitys Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WtNol. <br /> 0: X 1. NA-3082, HAZARDOUS WASTE, LIQUID - DM P DM Di 331 <br /> et N.O.S. , (BENZENE, LEAD), 9, PG III <br /> ad i <br /> d <br /> ' <br /> ut <br /> 2. <br /> �r <br /> 3. <br /> 4. <br /> 14.SpaetafHandling Instructions and Addidonal Information TSDaAG 83728609 OR14365 G <br /> ^ C • <br /> I)ER60171 • pk, <br /> 24H kNCY —468-1760—CH/SK/TFI—Contract retained #y generator confers agg cy authori' yon initial transporter to add r substitute ad itis 1 tr ns otter en at r' alt. <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 aro classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmemal regulations.If export shipment and I am the Primary <br /> Exporter,I petrify that the contents,of this consignment conform to the terms of the attached EPAAcknowledgment of nsent. <br /> I paddy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or( 1 am a small quantity generator)is true. <br /> Gen atorslOfferors Printed/Typed N e Si Month Day Year . <br /> al t 1 a <br /> ,� 16.IntemaAonal Shipments <br /> I Import to U.S. El Export .S. Pod ofentrylexiC <br /> Transporter signature(for exports only) Date leaving U.S.: <br /> irM <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Y itTsn <br /> _ MPrintedRyp NameSign Month Da^Y] Year <br /> �z Trans Printeddyped Name ' nature <br /> +YS Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑7 pe <br /> Y ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number' <br /> F- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facilitys Phone. ' <br /> to 18c.Signature mAlternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LJ420,DasgnatedFacifdyO.rer <br /> 2. 3, 4 <br /> r Operator:Cemlication of rec ipl of hazardous materials covered by the manifest except as etl m 18a <br /> -�Printed/Typed Name Signatu Month Day Year <br /> - I ab <br /> 12'IZLPjevious editions are ob rete. ESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />