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SSL SK SHIP#�2 liillllllll�llll <br /> 006520392SKS <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.1,.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000280645 1—{300-468-1760 <br /> 06520392 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> R der TIS 1071 <br /> 3533 Duck Greek Dr <br /> STOCKTON CA 95215-795, <br /> Generator's Phone: 209-943-3218 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY—KLEEN SYSTEMS INC TXROOOZ81205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322 50 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SER V I CES IN U.S.EPA ID Number <br /> 2247 G HIGHWAY 71 $ <br /> KIMBALL NE 59145 <br /> Facility's Phone 308-235-4012 NED981723513 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Type <br /> 13.Waste Codes <br /> cc 1 NON RCRA HAZARDOUS WASTE SOLIDS, DIS P 352 <br /> R (ABSORBENT AND OIL) <br /> w2. <br /> co <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TSD:KP 76*789385 RY12021 CSG: <br /> 24 HR EMERGENCY #1p-800-468-1760 (CH ! SK ! TFI)Q1 11H Qq jD �-1 <br /> 15. GENERATOR'510FFEROR'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 labeledlpiacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)ojWm am a small quantity generator)is true. <br /> Generato s! r Printed/Typed Name Signature Month Day Year <br /> a co <br /> — J l <br /> � 16.Internnal Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leavirg U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trar?pfer 1 Prirted17y ame <br /> a (� Signa tu Month Day Year <br /> f` - - , (' 4 ins <br /> a Transpo erg rintedff�5dillfame Signature Month Day Year <br /> -Q e..zs,�. .� r �' 31 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue <br /> ❑Pa cal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v <br /> Facility's Phone; <br /> w i 8c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 01. 2. 3. q, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of azardous materials covered by the man fest except clad in Item 18a <br /> PrintedlTyped Name Signa Month Day Y r <br /> 1, <br /> EPAForm8700-22(Rev.�) Previous editions are obsol . DESi ATED FACILITYTO DEST ION STATE(IF REQUIRED) <br /> 1)7371174/40793446 <br />