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I I Please print or type. d -LM�l 6 CS r I Form Approved. OMB No, 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page of 3. me R e P 4. Manifest Tracking Number WASTE MANIFEST 0, [7j ; � � � - - � - °r � 0 7 2 5 SKS 5 enerators Name and Mallin Address or s Site Address d different than mailing address) SAF��S7 L D I P ; f' 7 r r' t t 1 ! M - �filt?: I� x L 1 .71 1 4�1 f Generalor'sPhone: a U�( - L/v � - [� 3 y 9,1. ( 3 (D I� inHiW5OCO OLA CA y . 6. Tr9q;pod .fV2p�txy.Naroe SYSTEMS INC U.S. EPAIDNumber TXR00O081205 7. Transporter 2 CYYomttplaanny�Name U.S. EPA ID Number CLEAN HARBORS ENV SVC INC . MAD039 ' ' 8. Designated Facility Name and Site Address THERMO FLUIDS INC U.S. EPA ID Number 12533 SE CARPENTER DR CLACKAMAS a OR 97015 -8988 503. 7t�8-4616 ORG000025197 Facility's Phone: gat 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Contalners it . Total 12. Unit HM and Packing Group (if any)) No, Type Quantity WUVol. 13. Waste Codes 1 . NON-- RCRA ` HAZARDUU WAS14E SOLID _ DM P 223 o ( DRAINED /UNDRAINED USED bIL. FILTERS ) ? (� a UJ 2 — - w C9 4 14, Special Handling Instructions and Additional Information 24H EMERCGENCY#8001- 468- 1760—CH / SK / TF1 —Contract retained by generator confers agency authori y on initial transporter to add or substitute additional tr ns orters on ener.ator ' �i behaIf � 15. GENERATOR'SIOFFEROR'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, marked and labeledlp!acarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) rj I am a small quantity generator) is true. Generator's1O8eror s Pdnledffyped Name Signature Month Day Year % � All o mt, . y �r / tel 16. international Shipments ❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit __— ? Transporter signature (for exports only): Date leaving U.S.: W 17, Transporter Acknowledgment of Receipt of MaterialsLU F- TraaWer i Printed/Pped Name toSignature �'> Month Day Year z Trans rterPrinte Name Signa ly % Month Day Year 18. D saepancy 18a. Discrepancy Indication Space ❑ Quantic ❑ Type ❑ Residue Quantity El Partial Rejection El Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number 3 U LL Facilitys Phone: D40000010 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Ffevious editions are obsolete . DESIGNATED FACILITY TO GENERATOR 1 ) 78726'76 / 15603S