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SSL sx SNIR# �S 111111111 <br /> Please print or type. 22 F e4 Q � 3 ( } 0 4 T 1 S 4 1 1 k � � <br /> UNIFORM kAZARO0U5 1.Generator ID Number til n p(� � t� � S K <br /> CAL000280645 2.Pa of 3. me R Form Approved.OMB No.2050.0039 <br /> WASTE MANIFEST �..� Man' at Trackin Number <br /> 5.Generators Name and MailingAddnss ®®7 1 r9 , 1 4 SKS <br /> RySer T/sDuck <br /> Creek <br /> Generators Site Address{if different tan mailing address) 'T v V <br /> 3633 Buck Creek Dr <br /> STCICKTON CA 95215-7953 <br /> Generator's Phone: �9-943-3e�1$ <br /> 6.Tr§ <br /> b SYSTEMS INC U.S.EPA ID Number <br /> 7,Transporter 2 Company Name TX R000408 1215 <br /> SAN HARBORS ENV SVC INC. U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENV I RO NMENTAL SERVICES, IN MAD039322250 <br /> 2247 S HIGHWAY 71 uS.EPA ID Number <br /> Facility's Phone: 308-235-4012 KIMBALL , NE 69145 <br /> ga. 9b.U.S.DOT DescriptionNED981723513 <br /> {including Proper Shipping Name,Hazard ClasstD Numb <br /> HM and Packing Group(if any)) , er, 10.Containers 11.Total 12.Unit <br /> 1. W%l RCRA HAZARIDClUS WASTE , No. Type Quantity Wt.Noi. 13.Waste Codes <br /> o (ABSORBENT AND OIL) 3�LIDSDM P 352 <br /> L 2. <br /> 3. <br /> 4. <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> TSD;:KP RY120c1 CSS: <br /> 24H EMERGENCY#800-45$-17f:0—CH/SKlTFI—Contract retained Q�� k <br /> an initial trams r er a ar Y genera ar confers agency authari y <br /> 15. GENERA70R'SIOFFEROR'S CERTIFICATION: I he declare that the contents of this consignment are fully and accurately describedabove b the proper shippingr' <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary d {I <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgrnent of Consent. <br /> I certfy that the waste minimization statement identified in 40 CFR 262.27(a)Of I am a large quantity generator}or(b)2(iflaMa small quantity generator)is to <br /> neI cBrtf y t is wasPnnte minimi Name Signature <br /> Day <br /> J 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature{far exports only): i <br /> Date ieaving U.S.: <br /> OY17.TWer <br /> Acknowledgment of Receipt of Materials <br /> Of Transpor 1 rinted yped Name <br /> ® Signature Mo —Tavx Year <br /> CL <br /> Z Trans 2 Printed/Typed Name <br /> a� na Mo Day Year ' <br /> 18.Discrepancy <br /> 13 <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection <br /> 18b.Alternate Facifity for Generator) Man fest Reference Number. <br /> J U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility{or Generator) <br /> aMonth Day Year <br /> L 19.Hazardous Waste <br /> �Report <br /> �Management Method Codes{i.e.,codes for hazardous waste Vestment,disposal,and recycling systems) <br /> G1' 0 '—T— 2 3 <br /> 4, <br /> 20.Designated Facility Owner or Operator,CerVfration of receipt of hazardous materials covered by the mMqIGNA <br /> 18a <br /> Pr ntedlfyped Na e <br /> 10, Month Day Ye <br /> EPA Form 8700 22 Rev,12-1 Previous editions are obsolete. TEp FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)7371174/40793446 <br />