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SK SHIP# 241043569 <br />Please Driritflr tvoe <br />Form Approved. OMB No. 2050-0039 <br />EPA Foim8700-22(Rev.12.17) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2, Pae 1 of <br />9 <br />3. Emergency Response Phone <br />090-4-v �' -w <br />4. an(i�est Tra( ki Numb�jr �( <br />8 a� 9 SKS <br />WASTE MANIFEST <br />V a7 V <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />_ ,'roducts <br />1023 S Sacramento St <br />r AnT CA 952&U- 471 <br />Generator's Phone r'9-334 -1380 <br />6. Trans Merl Com ny Name EPA ID Number <br />3Y5TEP1S INCU.S. <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />CLEAN HARBORS ENy SERVICES INC <br />8. Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U. S. EPA ID Number <br />3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF .1 <br /># Nflit 1-5 UT 94083 <br />x35-884- 8915 0 f D99L: U1 <br />Facility's Phone <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNoi. <br />1 AOtE' NON HAZAkDOU6 NOY D.O.T. ,. <br />REGULATED, (WATER, OREF�1/, ~NPAA-,- <br />z <br />Z. <br />L <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information JIy GM 9299 0103boo `SG <br />24H.EOERGENCY#800-468-1760-CH/SK/TFi-Cgntract rgt�ined by generator confers a engV authot <br />on initial transporter- to add or substiiilite additional, transporters on genera -tor 9 behal <br />15. GENERATOR'S10FFEROR'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 labelediplacarded, 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 certly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 We. <br />Generalorsl0ffero s PrintediTyped Name Signature �� Month Day Yeat <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S Port of entrylee <br />? <br />Transporter signature (for exports only): Dale leaving U S <br />W <br />LU <br />17. Transporter Acknowledgment of Receipt of Materiats <br />Transporter 1 Printed/Typed Name Signature' Month Day Year <br />a <br />y <br />Z <br />/Typed PrintedlTyped Name Signature Month Day Year <br />[T7777 <br />F- <br />18, Discrepancy <br />18a. Discrepancy Indication Space quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number <br />18b. Akemate Facility (or Generator) U S. EPA IO Number <br />J <br />U <br />ra+- <br />Facility's Phone <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e. codes for hazardous waste treatment, disposal and recycling systems) <br />C <br />1. <br />2 3 <br />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 />Printed/Typed Name Signature Month Day Year <br />EPA Foim8700-22(Rev.12.17) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />