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SSL SK SHIP# 229407179 <br /> Please print or type. 0 0 7 1 5 4 1 0 S S K S <br /> 1.Generator ID Number Form Approved.OMB No.2060.0039 <br /> UNIFORM MNIFESTHAZARDOUS CA1.0010280645 2.Page 1 of 3.Emer,gge__yy Response Phone a,Nandest Traicking Number <br /> WASTE MANIFEST 1—tllOfd-468-17'60 S SKS <br /> 5.Generators Naand Mailing Address Generators Sde Addmss(if d Re ant Uan mailing add ass) J 107 1� <br /> Ryme der TIS 1071 <br /> 3633 Duck Creek Dr <br /> STOCKTON CA 95215-7953 <br /> Generators Phone: 209-943-3218 <br /> s.T <br /> ons 1 Coma' 1EmNa SYSTEMS INC <br /> U.S.EPA ID Number <br /> rxReeel2es <br /> 7.Transporter Company Name <br /> CLEAN HARBORS ENV SVC INC. U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address THERMO FLUIDS INC <br /> U.S.EPA ID Number MAD039322250 <br /> 12533 SE CARPENTER DR <br /> cLACKAMAS , OR 971015-89810 <br /> 503--79$-4616 <br /> Facility's Phone: ®R(,i:®OOOE5197 <br /> ga, 9b.U-S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(g any)) 11.Total 12.Unit 13,Waste Codes <br /> o. Type Quantity Wt Not. <br /> 0 1. NON—RCRA HAZARDOUS ATE SOLID DM <br /> <DRRIl(DRAINED/UNDRAINEDU USED aIL FILTERS) 41 P 223 <br /> = 2. <br /> W <br /> r, <br /> a. <br /> 4. <br /> 14.Special Handling Instructions and Addibonal Information TSD.TPO 81046013 RY12021 (� {� CSS.- <br /> 24H <br /> SG: <br /> 24H EMERGENCY#800-468-1760—CHISKITFI—Contract retained h � ���� "� <br /> y g mer at£or confers agency authority <br /> is. GENERATOR'VOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described a ve b the m <br /> marked and labeled/placarded,and are in all nes proper pappY g per shipping name,and are classified,packaged, <br /> pmentc ro rtothe terms transport EPA Acknowledgment <br /> international and national governmental regulations.If expod shipment andlam the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 cerdfy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I an a small quantity generator)is tru. <br /> GeneraforsfOffemrs Printed/Typed Name <br /> Signature M y <br /> zj 16.Intemanunal Snipments H <br /> ❑Import to U.S. ❑E ort ham U.S. Pad of entry/exit: <br /> i Transporter signature(for exports only): Data leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transrter I PrintedlTyped Name Signature <br /> 01i 1i••e]nv� Month Day Year <br /> T Printe Name Smord Montle D�aTy Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑ <br /> Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility for Generator} <br /> � U.S.EPA ID Number <br /> t9 <br /> Faciliys Phone: <br /> H18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> 4 <br /> z <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 3 <br /> 4. <br /> 20.Designated Fadliry Owner or Operator.Certifi n of receipt of hazardous materials covered by the manifest exce s nd in I a <br /> Printed/Typed Na Signatu Month [}ay Year <br /> �LV�1 d�1 H ,�vt. ati�CJ• jr <br /> EPA AM 7reviouseditionsareohsolete.78779/156DESSG ATEDFACiLITYTOEPA'se•MANIFESTSYSTEM <br />