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Please print or type. Form Aooroved. OMB No 2050-0039 GENERATOR UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number C A C 0 0 3 2 1 6 8 4 4 2. Page 1 of, / 3. Emergency Response Phone 800-556-9090 4. Manifest Tracking Number 0 2 2228736 JJ K Generators Name and Mailing Address Generators Site Address (if different than mailing address) S&S Transportation .S&S Transportation 320 South C St. 2005 Krohn Rd Monmouth IL 61462 Tracy CA 95377 Generator's Phone: 3 0 9 2 5 5 - 9 8 8 6 I Transporter 1 Company Name U.S. EPA ID Number ANC ,OH MARINE 1 C A 0 9 0 7 3 7 0 i3 8 7porte0 Co any ame / U.S. EPA ID Number I (/ , Designated Fklity Name and Site Address U.S. EPA ID Number C ROSBY & OVERT() 14 *1630 W. 17TH STREET LONG BEACH CA 90813 Facility's Phone: 562 432-5445 I C A 0 0 '-' f3 4 0 9 0 " 0 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt./Vol. 1' Non-RCRA Hazardous Waste Solid Diesel, Debris) 352 0 0 4 DM C0800 P 2. 14. Special Handling Instructions and Additional Information ERG Pock in V•Ei.:1-7_. - Wear appropriate .'I'F, when handlino. Job# 400.13.42520 9—b-3-Pcfc4 .1.) ERG 171 (4x55) 9961 1 15. GENERATOR'SIOFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Month Day Year Generator's/Offeror's Printed/Typed Name Signature __..---_2- -) Justin Duke on behalf of S&S Transportation I el_ .----_,....----- ,----- •c_:________ I 0 21 0 91', 3 _1 f-- 16. International Shipments ...----- Import to U.S. LII Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: ce tu n_ en m 17. Transporter Acknowledgment of Receipt of Materials Transport r 1 Printed/Typed Name Signature Month Day Year I -,41i00-7 Transporter 2 nted yped Name 4i.,' Month Day Year Si gnature / I -.. ,.." 4-- DESIGNATED FACILITY "" 18. Dis,it pan4 Discrepancy Indication Space )Li L Quantity LIII Type LIII Residue Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted inilem 18a Printed/Typed Name Signature Month Day Year ,--'---- ' ----2---------_ - - 1 ''-7-/ 7 ,,,, J----7 I - -/-'3" ' I 7 I ZO I .:'-'-- EPA Foriv.17_(.9) 2 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEI i