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SSL SK-SHIP* 231670192 IIINIIIIININNNNNIIIINIINII� <br /> 0074774273 KS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.lailej of 1 3. me R P 4.Manifest Tracking Number <br /> WASTE MANIFEST CRL000392916 -���- �0 007477427 SKS <br /> 5.Generators 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 /> Generators Phone 209-239-4188 <br /> 6,Tr'ygspprgjrfmpanv.Name SYSTEMS INC U.S.EPA ID Number TXROOOSS1205 <br /> 7.Transporter I2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW ILLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-6200 CRD980675276 <br /> i Phone: <br /> 9a. 9b.LLS.DOT Descnpdon(including Proper Shipping Name,Hazard Class,ID Number, 10.Conwiners 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WL/Vol. <br /> 1 N-RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> o (ABSORBENT AND OIL),-, R <br /> 9 0 � Ido <br /> Z Z. <br /> Ulu <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Intonation TSD:BL 83477820 OR14365 �UNI; <br /> (y(� <br /> 24H EMERSENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers aggency authori y <br /> on initial transporter to add or substitute additional trans orters on enerator' 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 EPAAcknowledgment 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 /> GeneratorsrOferors Pnnted7Typed Name G� �, Signature Month <br /> Month Day Year <br /> �N 5' re, aY c. �2�� j!( 11,�, <br /> 16.International Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Pon of entrylei. <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> K 17.TransporterAcknowtedgment of Receipt of Materials <br /> w <br /> � T porter 1 PnntedRyName Signature Monts Day Year <br /> z Transporter 2 Printedflyped Nametum Month Day Year <br /> Wei!" Altimm 106 lir Ito <br /> } 18.Discrepanci <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 1 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1 Prmtedrryrd Name Sgnatu Month Day Year <br /> EPA Fglia8700221(28412-171 gguseditionsareobsolete. DESIGNATED FACILITY TO EPA'se-MANIFEST SYSTEM <br />