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SSL SK SHIP# 228243205 <br /> 9 a <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Erne enc ResRpgse Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAI..P!$01a20r�,�, �,,.���+�,�176�# <br /> WASTE MANIFEST 007040375 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> JC Trucking Inc <br /> 14.15 W,w Anderson 5t. <br /> STOCKTON CA 95206-8000 <br /> Generator's Phone: 209•-466--3282 <br /> 6.Tr ns rier 1 Com ny Name U.S.EPA ID Number <br /> F F'ETY-w LEEN SYSTEMS INC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322 250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE � GA 95133 <br /> CAD0534943 i0 <br /> 408-441-09KJ <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> X 1. NA3082, HAZARDOUS WASTE L.I OU I D, DM ? �y P D007 DAB 213 <br /> O N.0.Sm (PETROLEUM DISTILLATES LEAD) <br /> q , 9, III � <br /> z 2. <br /> L <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD!SJ 79814127 JC 10836 CSG S <br /> I)ERG#17I <br /> 24H EMER69NCY# -488-176@-CH/SK/TF'I-•Conrtract retained by generator confers agency authori y <br /> on initial ubstitute additional, transporters on gengaratorl s behalf. <br /> 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, <br /> 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 <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 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials f <br /> Transpo er 1 Printed/Typed Name Signature /. I -j 7 Month Day Year <br /> 0 4, <br /> Z rTransporter 2 Pritedrryped Name Signature /a �"�° Month Day Year <br /> F , <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste oatment,disposal,and recycling systems) <br /> p 1• 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17�) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 118600871/1827950 <br />