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SSI_ SK 9141 P# 230944664 11111111011111111 <br /> 0074341655 K5 <br /> Form Approved,OMB No.2050-0039 <br /> Please print or type. <br /> 1.Generator lO Number 2.P ge of 3.Emer a Re rise 4.Maniket Tacking Number 100743916 ��� <br /> UNIFORM HAZARDOUS rAL000392916 1- �1�- 58 7�m <br /> WASTE MANIFEST � <br /> 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> O' Reilly # 3501 <br /> 515 E Yosemite Ave <br /> MANTECA CA 95336-5837 <br /> Generator's Phone: `�-��—t'.39-4188 <br /> U.S.EPA ID Number <br /> s.T ner 1 Com any Name TYR000081205 <br /> r�FFET`I-P'•l_EEN SYSTEMS INC ' <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name MAD039322250 <br /> CLEAN HARBORS ENV SVC INC. <br /> 8.Designated Facility Name and Site AddressCLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> ., <br /> 1021 BERRYESSA ROAD <br /> RAN'Ji , CA 95153 <br /> 40t3-441-096^c CAI3059494310 <br /> Facility's Phone' <br /> 9a 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, jNo. <br /> *Iijotal 13.Waste Codes <br /> HM and Pacing Group(it any))NDN-RCRA HAZARDOUS WASTE, SOLID, 181 <br /> o ABSbRBENT AND OIL?, <br /> 0 <br /> z z. <br /> W <br /> C7 <br /> 3. <br /> 4, <br /> 14.Spedal Handling Instructions and Additional Information TSD:SJ 826672E.3 4365 Q� <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract r t lned by generator�onfers a en . author y <br /> 9S hphaif. <br /> on initial <br /> i � . r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Mis consignment are fully d 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.H export shipment and I am the Primary <br /> Exporter,I cerffy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I ceNly that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity genera r)or(b)(RI am a small quantity generator)is We. <br /> GenemtorslOfierors Pnntedrlyped Name Sig Month Day Year <br /> /1- AL____ ji 1 la jar, <br /> 16.International Shipments ❑Impod to U.S. Ll Export from U.S. Port of entry/exit: <br /> i <br /> Transporter signature(for exports only)'. Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> W Month Day Year <br /> Tran iter 1 Printe dlfyped game SignaWre <br /> a1eAa_Mr� (`tl Cy C?3 1 a aV <br /> W Transporter 2 PrintedlTyped Name aNre Monty Day Year <br /> 9 103 17 1 20 <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> CD Q <br /> z <br /> V5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> V5 1' 2. 3. 4. <br /> 20.Designated Fac <br /> l ilty Own o(Operator Certification of receipt of haurdous materials covered b the manifest except Cold in Item <br /> 11I Printed(ryped awe gnaw Month Da Year <br /> 01 <br /> EPA Form 8700-22 Rev.12-17) Previous (tions are solete. DES ATE CILITY TO EPA's e•MANIFEST SYSTEM <br /> 117 361'r_5M05 X9605 <br />