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SSL SK SHIP# 231514090 <br /> Please print or W. Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Eme Reorse Phone j4AMaW" TdcIdn9 Number <br /> WASTE MANIFEST CAL200412859 1 IT9W41�&- 1760007461- 855 Sno <br /> If 0 <br /> 5, GoneraWs 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 95203-4%00 <br /> Generators Phone: 661--823- 3731 <br /> Company U.S. EPA ID Number <br /> Transporter1Y=4(LIEEN SYSTE14S INC TXR>�000A1ctZIS <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> CLEAN HARBORS ENY SVC INC. MAM9322250 <br /> 8, Designated Facility Name and SiteAddress CLEAN HARBORS OF WILMINOT13N U.S. EPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTON , CA 90744 <br /> 3f >�-935-9'398 GAA04442�3935 <br /> Fadlitys Phone: <br /> ga, gb. U.S. DOT. Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13. Waste Codes <br /> HM ands! . Group ('f any)) No. Type Quantity WtNoi. <br /> 1. N9ldE NON RCRA HAZARDDW TASTE L112UIDS DM � � d P MI <br /> o , ( OIL W/ LESS T HAAT 10% WATER ) Ni% <br /> z 2. <br /> W <br /> 3. <br /> 4, <br /> 14, Special Handling Instructions and Additional Irdomratim TSD : W I 83303067 CAS7679 CSG e <br /> 24H EMERGENCY#M0 469- 176@-CH/SK/ TFI - Contract retained by generator confers agency atkthori y <br /> nn i1nifial > q n <br /> rip r1pn4p <br /> 15. GENERATOR'SfOFFEROR'S CERMCATiON: I hereby declare that the contents of this consignment are fully and awxaWy desalbed above by the proper shipping name, and are classified, packaged, <br /> marked and labeledlplacanded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. V 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 26227(a) (d 1 am a large quantity generator) or (b) (if i am a small quantity generator) is IV, <br /> Generaton's/00eroes Pdntec Typed Name Signature ! Day <br /> Year <br /> 16. International Shipments 11 Import to U.S. ElExportfrom U.S. Port of entry/exit .—. <br /> it --- <br />' ? Transporter signature (for exports ordy): Date leaving U.S.: <br /> i <br />€ IX 17. TrmtsporterAdmoxledgmentofReceipt ofMaterials <br /> aW- Trii rter 1 Pdn Name Signature D <br /> ` t �I��77rr,,,��,,�n 014V 1A, <br /> Q Trarspot r3grintedffypod Name Signature <br /> Month Day Year <br /> N s <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space ElQuantity ❑ Type ❑ Residue Paul Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b. Alternate Facility (or Gerneratnr) U.S. EPA ID Number <br /> J <br /> U <br /> rd+- Facility's-Phone: Month Day Year <br /> w 18c. Signature ofAitemate Facility (or Generator) <br /> Q <br /> z <br /> N19, Hazardous Waste Report Management Method Codes (i.o., codes for hazardous waste treatment, disposal, and recycling systems) <br /> us 1 2 <br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Itnm 183 <br /> Pdntedlfyped Name Signature Day ear <br /> MANAMA <br /> EPA Form 87(10-22 Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 1 ) 879347 / 1971377 <br /> 5 Dck�" We/> 036 r <br />