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SSL SK SHIP# 231514088 <br /> Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. e R Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAL81:f0412859 1 1 !4 1716A1007491854 S K a7 <br /> 5. Generator's Name and Mailing Address Generator's Site Address (d different than mailing address) <br /> CalPortland — Stockton West <br /> 2845 W. Washington St <br /> STOCKTON CA 95 --0000 <br /> canasta's Phone: 66 f"'82.3"37;31 <br /> s. TSF�FETY WLEEEN SYSTEMS INC u.s. EPA IDNumber TXR S1205i <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. i+�03932225@ <br /> 8. Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S. EPA ID Number <br /> 3 MILES <br /> EAST, 7 MILES NOR!O � KNOLLS EXIT 419 OFF I -80 <br /> 435�884--�8915 KUTD99131211748 <br /> FacrlWs Phare: <br /> ga 9b. U.S. DOT Description (rnduding Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12, Unit. 13. Waste Codes <br /> HM and Pad dng Group (deny)) No. Type Quantity Wt AlbL <br /> I idONO&-RCRA HAZARDOUS WASTE, SOLIDS � DM P 352 <br /> o ( OIL, DIRT, SAND, ABSORBENTS AND <br /> bIESEL FUEL ) v WA <br /> Z 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information TSD u* GM 83303067 CA67879 CSS tt <br /> 24H EMERGENCY#M0 468- 1760CH/SK/TFI -Contract retained by generator confers agency authari l <br /> 15. GENERATOR'SIOFFEROR'S CE T IFJCATION: I hereby declare that the axdants of this consignment ale fully and accurately described above by the proper shippag name, aid are classified, packaged, <br /> marked and IabeieWpiacarded, and are in all respects in proper condition for transport according to applicable internationaland national gmvemmental regulations. If export shipment and I am the Primary <br /> EyxxW i certity that the contents of this consignment oonfono to the terms of the attacked EPAAdmowledgment of Consent <br /> 100* that the waste minimization statement identified in 40 CFR 282.27(a) (d I am a large quantity 9anefator) or (b) (41 am a small quantity genamta) Is true. <br /> GeneratotslOrfenr's PrinkNTyped Name Signature Mantf! Day Year <br /> 16, Internafnonal Shipments El import to U.S. _ ❑ Exportfrom U.S. Pat oira. ylexft <br /> — - — <br /> Pam <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TranspoderMwwledgment of Receipt of Materials <br /> UA <br /> Transp iter 1 Printed/f Name Signature. ! ,� t Month Day Year <br /> off- ' \ L ), . �7'l Y i `,, - / t(, ,t } t `> � • ' ft? '+ 1 <br /> U) <br /> Transporter2 Priido L?ype T flame Signature j Month Day Year <br /> 18. Discrepancy n / <br /> 18a. Discrepancy indication Space El Quantity ❑ Type ❑ Residue EI Pal& ne)e tion ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J_ <br /> V <br /> rQ FacrTity's Plane: <br /> w 18a Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> 19. Hazardous Waste Repot Management Method Cafes (.e., codei for hazardous waste treatment, disposal, and recycigg systems) <br /> ca <br /> LU 1 . 2. 3. 4. <br /> 20.Designated Facility Owner oroperate: Certification of recast of hazardous materials covered by the manifest except as noted In tem 18a <br /> rirtted/fype Nara ' nature Day Year <br /> EPA Farm 8700-22 (Rev, 12-17) Previous editions ate obsolete. GENERATOR'S INMAL COPY <br /> 1 ) 8793885119713798 ff � 0 <br />