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SSI_ SK SHIP#I 223295027 Ill III ill IIll 1I11111p111llll111111 <br /> 0063406605 KS <br /> Please print or type,(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAD962497828 4.Manifest Tracking Number <br /> WASTE MANIFEST Z 1006340660 SKS <br /> 5.G ner tor' ame and n Addre s Generator's Site Address(if different than mailing address) <br /> Lia ran51Sp0 Cm5 <br /> 2005 Krohn Rd <br /> TRACY CA 95377-9120 <br /> 209-835-6779 <br /> Generatots Phone: <br /> s T94FrVY4ffya SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number ,' <br /> dvso <br /> 8.Designated Facility Name and Site Address THERMO Fl ll U.S.EPA ID Number <br /> 12533 SE CARPENTER DR <br /> CLACKAMAS OR 97015-8988 <br /> 503-788-4616 OR0000025197 <br /> Facility's Phone: <br /> 9a 9b.U&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 WiNor <br /> o (DRAINED/UNDRAINED USED QIL FILTERS) I So <br /> z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions andAdditional Information a. 2 <br /> 24 HR EMERGENCY H1-800-468-1760 (SK / TFI) 1-70 <br /> 5 <br /> AUTH AS "AGENT—FOR BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <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 labeledlplacarded.and are in a€I 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 carlify 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)Nf I am a Wall quantity generator)is true, <br /> Generator'slOf€erofs PrintedlTyped Name Signature Manch Day Year <br /> X x Oar <br /> 16.International Shipments <br /> ZImport 1 U.G. ❑Export from U.Sool Port of entry(exit: <br /> Transporter signature(for exports only): Date leaving LLS <br /> 17.Transporter Acknowledgment of Receipt of Mi <br /> aterials <br /> Transporter 1 Pnnted7Typed Name Signature Month Day Year <br /> CL - u 20 17 <br /> Za Trans er 2 PrintPttllTyped Name igna ure Morth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity 1-1 Type ❑Residue 1:1 Partial Rejection Ll Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) D.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W <br /> 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> to <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> r_ U 4__Ax�_ zo I Li I b <br /> IVIYORM -61,fviouseditions Ag obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQU RED) <br />