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SSL SK SHIP#ei��TI NIIIIIIINIIiIIiIIIIIIIII III III <br /> /L � Iq �2. a�1 00731l4193K5 <br /> Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAI.-000310616 2.Pat Id" 3.EmergeRGy RespoAse lhgrte� 4.Manifest Tracking Number SKS WASTE MANIFEST �I 1 ti¢n0 4btl /b 007318419 V K V <br /> 5.Generators Name and Mailing Address Generator's Site Address if different than mailing address) <br /> Garibay' s Cleaners <br /> 200 N Main St <br /> MANTECA CA 95336-4633 <br /> Generators Phone: 209-239-0647 <br /> fi.Tr-Fs�t�,Co—X SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 YCompany Name U.S.EPA ID Number <br /> CLEAN HA BORS ENV SVC INC. MAD039322250 <br /> 8.Designated Faulty Nyneand Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL NE 6.9145 <br /> 308-235-4012 NEA981723513 <br /> Facility's Phone: <br /> 9, 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(a any)) No. Type Quantity WVvol. <br /> X 1 UN2810 WASTE TOXIC LIQUID ORGANIC N.O. S. DM P FOL712 D007 D039 <br /> o (TETRACHLOROETHYLENE TRILEHLOROETHYLENE) <br /> E•. 1 PGIII RQ(F002) ' (� ( �U D04Q 741 <br /> z z. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD-KP GA 11 85G� <br /> 1)ERG#153 <br /> 24H EMERG�NCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers aggency authori y <br /> on initial transporter to add or substitute additional trans Grters on eneratar' 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 curtly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I car*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 /> GeneratorslORerol Pnntedrryped Na Signature( Month Day Year <br /> 1, 4 ee 1 ' �-� it1 14 <br /> 16.International Shipments <br /> F <br /> 1:1 Import to U.S. - Export from U.S. Port of entrylexif <br /> ? Transporter signature(fa exports only): Date leaving U.S.: <br /> W 17.TranspaterAchnoMedgment of Receipt of Materials <br /> TrepFporle�1 Pn,tey^d poem S Signature Month Day Year <br /> O <br /> Z Ten erg Pnnted7Typed Name nature Month Day Year <br /> Z <br /> t1b.Discrepancy <br /> laa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Pareal 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 /> F18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.•codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certificafion of receipt of hazardous materials covered by the manifest except as noted in Item lea <br /> Prriinnttre�,tlRypped2Name <br /> @ �2 Signature Month Day Ye <br /> EPA <br /> l) /b01e8/1508�avious editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />