Laserfiche WebLink
SSL SK SHIM'# &� rz.M 11111111111111111 IN III <br /> 2, 1T*%a -1 "Z33 0 0 5 5 2 2 9 2 9 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pag 1 of 3 Em Ike se pe 4.Manifest Trackin Number <br /> WASTE MANIFEST CAD98�4978c8 1 � fGO 0055�Z 2929 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Cal Trans Shop 10 Cws <br /> 2005 Krohn Rd <br /> TRACY CA 95377-9120 <br /> Generators Phone: 209-835-6779 <br /> 6.T§Wt'9`fVoW1-tRe SYSTEMS, INC. U.S.EPA ID Number TX R000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS BUTTONW I LLOW, LLC U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-6200 CPD98OE75276 <br /> Facility's Phone: <br /> 9a 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 /> 1. NON RCRA HAZARDOUS WASTE SOLIDS (NON ' DM P 352 <br /> o RCRA HAZARDOUS WASTE SOLID (ABSbRBENT <br /> AND OIL) ) <br /> z 2. <br /> L <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:BL 70791871 CA47950 CSG: <br /> 24 HR EMERGENCY #1800-468-1760 (SK i TFI) I ' J( 2� 31r <br /> AUTH AS "AGENT—FOR" <br /> BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'S/OFFEROR'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 natiom3l 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 generato r(b)(i am a s tity generator)' tru <br /> Generators/Offerors Printed/T Name Sign r Month Day Year <br /> t t <br /> —r 16.International Shipment ❑ <br /> zImport to U.S. ❑Export from U.S. ort of en ry,exit: <br /> Transporter signature(for exports only): to leavin <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans orter 1 Printed/Typed Name i a Month Day Year <br /> BCL <br /> N <br /> Q Tran orter 2 Printed/Typed NameSign ure Month Day ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C3 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z1 <br /> 0 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 6�Lw <br /> 2. 3. 4. <br /> 20.Designated Facility OOwnner perator:Certification of receipt of haz ous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name L'V Signature Mo Day <br /> EPAFn�tp,g% ..(R, Pqf��p � editionsare obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 11 L-: C/ f . JL <br />