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7142 SK SHIPO 210871474 D T S t=. 0 2 S S S . U 51 4 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Forth Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2 Pa 1 of E n P 4.Ma ifest T ck ng umber <br /> WASTE MANIFEST <br /> cAL000097672 � ' �` � 0 0 432 FLE <br /> 5.Generator's Name and Mailing Address Generators 'te Address(if different than mailing address) <br /> RITE- WAY SCREW PRODUCTS <br /> 1649 .11 Victor Rd <br /> Lodi. , CA 95240-0862 <br /> Generators Phone: 209-368-2640 <br /> 6. YC aSYSTEMS. INC. U.S.EPA ID Number TX ROOOOB 1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS BUTTONWI LLOW. LLC U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW CA 93206 <br /> fi61-762-6233 CAD980675276 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contairiers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. <br /> 1-NONE. NON RCRA HAZARDOUS WASTE SOLIDS. DM P 352 <br /> o (OILY DEBRIS), N/A / 3t7o <br /> � f <br /> Z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14:Special Handling instructions and Additional Information TSD s 116595 61475493 3087610 CSG <br /> 24 HR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurst*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 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 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> enerato e s nn y ame r ay tear <br /> i 1A.Intemational Shipments <br /> Z El Import to U.S. ❑Exportfrom U.S. Port of entrylexit: <br /> Transporter signature fore its only): Date leavi U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ranspo Printed/Typed Nlam r re Month Day year <br /> CL <br /> QTranspWr 2 PrintedlTyped Nerfili Signature month Day Year <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typa ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> 4 <br /> Facilitys Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> U, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment(Fsposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> f <br /> 2Q.Designated Facility Owner peraior.Certification of receipt of hazardous materials covered by One manifest except as notedjpA7 18a <br /> PrintedlTyped Names Signagre Month Day Year <br /> G00-1 -9*4, <br /> A A!1�4 -ACA Z <br /> Eg�Fi!96MV.39B( evious editions are obsolete. DESIGNA FACILITY TO DESTINATION STATE OF REQUIRED) <br /> 2 11588.0609 <br />