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Please print or t I.e. s Form Approved.OMB No.2050-0039 <br /> _ UNIFORM HAZA, OU5 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number 1f <br /> WASTE M .,v(FEST , `:A�? 3 �S :(— IQt—�5taE3— f F,Z! SKS <br /> 5.Generat Krs Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> R L. Diesel Service2417 West Ln 11 <br /> STOQKT ON �'` CA 95205-M2602 <br /> denera(oes Phone: 209--4E6-4725 <br /> 6.Transporter 1 Company Name { U.S.EPA ID Number <br /> SAFETY—KLEEN SYSTEMS INC TXR@l a Tei: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039:3222 sD <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS BAK] JOSE U.S.EPA ID Number <br /> 1021 BERRY1=SSA ROAD <br /> SAKI JOSE M CA 95133 <br /> Fai Phone: <br /> 408-441--0962 CAD059494310 <br /> ga, 91.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. r <br /> 1 NUN KRA HAZARDOUS WASTE SOLIDS <br /> (DEBRIS, PETROLEUM HYDROCARBONS1 <br /> rL '' <br /> z W 2. <br /> II 3. <br /> t 4. <br /> 14 Special Handling Instructions and Additional Information Si <br /> 24H EMERGENCY#800-46,B-1760—CHdSK/TFI--Conitract retained by generatar cort•Fer� ��en�y �tuthar,i y <br /> 1 15, GEN ERATOR'S10FF@ROi2'S CERTIFICATION, I hereby declare that the contents of this consignment are fully and accurately described dbove by the proper shlia Warne,and are classified,package , <br /> marked and labeled/placarded,and are in all respects in proper condi8on 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 EPA Acknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 Cl 262.27(a)(if I am a large quantity generator)or (afa-am a,small quantity generator)is true. <br /> Generator'sl0fferor's PrintedlTyped IN e SignaM Month Day Year <br /> 16.International Shipments <br /> ii ❑Import to U.S. ❑Export from U.S. ib <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17,Transporter Acknowledgment of Receipt of Materials <br /> Transpii <br /> iter 1 PrintedlT ped Name Signature Month Day Year <br /> CL f tiA , t" <br /> Cn <br /> 7_ jr 2 Prinr tedlTyped Name 5' Month Day aG <br /> 18.Discrepancy <br /> IBe.Discrepancy Indication Space ❑ Quandty Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(pr Generator) U.S.EPA ID Number <br /> J <br /> I Facility's Phcna: <br /> W 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> rn 19.Hazardous Waste R port Manag ni Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1. 2. 3. 4. <br /> 20.Designated Facility Owner or tor.Ce tification f receipt of z dons materials covered by the manifest except as noted in tem 1 <br /> PrntedlTyped Name ` Signature IT <br /> EPA Form 8700-22{Rev.12-17j sous editlons re o s le DESIGNATED FACILITYGENERAT R <br /> 1}8�795;�E�/t63P;,�o�4D 2•}"T�r�'��t� �-3-5#�7�7� <br /> � r <br /> i <br />