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SSL SK SHIP# 218188135 I IIIII� IIIIIIIIIIIIIIIIIIIIII IIII <br /> L,( 00524431 6 S K r <br /> Please pent or type.(Form des nad for use on elite(12-pitch)typewriter.) e 1 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generator ID Number CAD981375157 12-InfMg tof 3 ��f4"sef'�f0 4.6lanifest TrackiNumber �( <br /> WASTE MANIFEST 0 0 5244816 S K S <br /> 5. nerator's me n ai ng Address Generator's Site Address(if different than mailing address) <br /> ecyc�ec� i�ers <br /> 800 W Church St # B <br /> STOCKTON CA 95203-3206 <br /> Generator's Phone: 209-464-6590 <br /> 1 Teats l or_rftV SYSTEMS. INC. U.S.EPA ID Number TX R000081205 <br /> 7 Transporter Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address CLEAN HARBORS BUTTONWILLOW, LLC U.S.EPA ID Number <br /> :500 LOKERN ROAD <br /> P(JTTONWILLOW , CA 93206 <br /> 661-762-6200 CAD980675276 <br /> Facd ry's Phone <br /> qa 9b.U.S.DOT Description(including Proper Snipping Name.Hazard Class,ID Number. 10 Containers it Total 12.Unit 13.Waste Codes <br /> lilt and Packing Group(if any)) 'vo. Type Quantity Wt./Vol. <br /> ONE NON RCRA HAZARDOUS WASTE SOLIDS, DM P 352 <br /> 0 (ABSbRBENT AND OIL), N/A 3�� - <br /> a V <br /> w <br /> Z <br /> w <br /> 0 — <br /> 3 <br /> a <br /> 14 Special Handling Instructions and Additional Information TSD:BL 69116281 RE23711 CSG: <br /> 14 HR EMERGENCY #1-31x0-468-1760 (SK / 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 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 cert ty 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 true. <br /> Gen I e'Offeror's Pnnted/Typed�l yne Signature Month Da; Year <br /> J 10.In emational Shipments <br /> ❑Import to U S ❑Export from U.S. Port of entrentry/exit: <br /> . <br /> Transporter signature(for exports only): Date leaving U.S: <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> OTransportnntedlTyped Name Signature Month Day ear <br /> r� VMonth Day Year <br /> Z <br /> TranspNW 2 PnntedrTy Na ignature <br /> rY <br /> F- <br /> 18 Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> t— <br /> 18b.Alternate Facility(or Generator) US EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone Month Day Year <br /> LO 18c,Signature of Alternate Facility(or Generator) <br /> t— <br /> Q <br /> Z <br /> L9 19 Hazardous Waste Report Management Method Codes(i a codes for hazardous waste treatment disposal.and recycling systems) <br /> U) 1 2.3 . 4. <br /> 0 <br /> 20 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prinlel,Typed Name Signature Month Day Year <br /> C1,4,4, 1 r. <br /> EPAfojw$71A SEE �+N� l^ 'Qus editinn�are ob ie!e DESIGNATED FACILITY TO DEST ATION STATE(IF REQUIRED) <br />