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. SK SHIP# 227715651 Please print or type. Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page,1 of 3.1me cin R s o se Ph9�� 7601016776967 est Tracking Number SKS UNIFORM HAZARDOUS C�1L' �J i Q� 3 �. `� ,p gta V I�V WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) JC Ir'ucking me X41.5 W. Anderson St. STOCK ON OA 95206-0000 Generator's Phone: s.Tre�r worgganM SYSTEMS INC u.s.EPAIDNumber TXR000081805 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENVIR NSM NTAL SVC INC. MAD035328250 8.Designated Facility Name and Site Address CLFAN HARBORS ENV I FtONMENTAL SERV ICES9 IN U.S.EPA ID Number 247 S HIGHWAY 71 KIMBALL ' NE 69145 308-235-4010 I`ED981723513 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 1. UN1263a IHRSTE PAINT, 31 PG II F@01 Eads rl12*1 O D005 B006 212 z 2. W c� 3. 4. 14.Special Handling Instructions and Additional Information M B KP •19257806 J !08,36 I}ERGVIIP8" -n4H EMEKP, NCY#P,00-488--1.760-CH/SK/TFT-Contract retained by Renerator corners a, .ency authari y on initial transporter to add' r substitute rddiwi .iratester= genera sr 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 labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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)(if I am a small quantity gene`tor)is true. Generator's/Offeror's Printed/Typed Name Signature dI, f Month Day Year . 1 1 V 16.International Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entry/exi. Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printed/Typed Name Signature Month Day Year aw ,.., ., Cl) Transporter 2 Printed/Typed Name Signature Month Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility's Phone: W 18c.Signature of Alternate 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 Printed/Typed Name Signature Month Day Year EPA m 7 Q. Rgv.12 Pr vious editions are obsolete. GENERATOR'S INITIAL COPY