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SSL SK SHIP## 2 '49834 11111111111111111111111111 HE 1111111 <br /> 0 0 5 2 4 4 7 8 8 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t.Generator ID Number CAL000239900 12.Pagllof 31FjPgW1Mjw 4.Manifest Trackin Nurn r p �( <br /> WASTE MANIFEST O O 5 Z `t 7 8 8 SKS <br /> (S <br /> 5. erator'${Name and blDTI YailineddrV, �h a S A�� Generators Site Address(if different than mailing address) <br /> flC DTI SM <br /> 3295 N Ad Art Rd <br /> STOCN.TON CA 95215-2200 <br /> Generators Phone: 209-931-7940 <br /> s.�1lCaq�rEReSYSTEMS, LNC, U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN -HARBORS SAN ,LOSE LLC U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE CA '351,33 <br /> 408-441-096= SAN <br /> 310 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WL/Vol. 13.Waste Codes <br /> K 1. 1z17� , WASTE GASOLINE, 3, PG 11 DM DOOI I DO18 1213 <br /> 0 <br /> � 1 I <br /> z z. CINE, NON RCRA HAZARDOUS WASTE SOLIDS, DM P 352 <br /> 0 (ABSORBENTS CONTAMINATED WITH OIL) , N/A <br /> 3. JAN I1 <br /> 4. 9.—j <br /> 14.Special Handling instructions and Additional Information TSD:SJ 59195801 ST27754 CSG <br /> 1 )ERtG##12'8; <br /> 24 HR EMERGENCY #1-800-468-1750 (SK i TFI) <br /> AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am 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 certify 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 26227(a)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is true. <br /> GeneratorslOffe PrintedrTyp Name ignature Month Day Year <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export frau U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Tra ksporter Acknowledgment of Receipt of Materials <br /> Tra116 o r`1 PrintedT arae Signatu Month Day yl ear <br /> rC <br /> zQ Transporter 2 Printedrryped Name Signature Month Day Year <br /> f- <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 /> U <br /> cc <br /> U_ Facility s Phone: <br /> w1Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> M 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in item 18a <br /> Printedrryped Name Signature Month Day Year <br /> EPh""6910-2MI�.?4_j)f1X�T/L9Ls1r$bf ie1'L-?9P4 DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br />