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v3+Uo54 3 I � ��il � Il1ll�lllllilll� I� <br /> SSL SK SHIP#�*3�Os— <br /> 005862859SKS <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1,Generator It)Number 2.Pagell of 3.Em cy Res nse Phone 14.Manffeet Tracking Number <br /> WASTE MANIFEST CAD982497828 1 1-80n0-MP 1760 0 0 5 8 6 2 8 5 9 SKS <br /> 5.Generators 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 /> B.Trer�1 Company Name U.S.EPA ID Number <br /> SRFETY—SRLEEN SYSTEMS, INC. TXR000081205 <br /> 7.Transporter 2 Company Name U.S ID r <br /> DIA11 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS BU NW I L[ OW, LLC U. .EPA ID Number <br /> 2500 LOKERN ROAD <br /> #IUTTONWILLf}W , CA 93206CAD980675276 <br /> 561--762-6200 <br /> Facility's Phone: <br /> ga. 9Ib.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 WtNol. <br /> c 1. NON RCRA HAZARDOUS WASTE SOLIDS (NON DM P 352 <br /> RCRA HAZARDOUS WASTE SOLID (ABSbRBENT l �] S <br /> a4 AND OIL) ) <br /> z 2. <br /> w <br /> t.7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:BL C A47950 GSG <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) �0 VV 94 <br /> 011TH Aq r, <br /> 15. GENERATOR'SIOFFEROWS 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 labele&placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental 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 aftarhed EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantify generetor (b)(if I am a small quantity generator)is true. <br /> Generators1011erors PrintaCyped Sign re Month Day Year <br /> ,LN <br /> J 16.International Shipments <br /> F ❑import to U.S. ❑Export kom U.S. Part of entrylexit: <br /> Z Transporter signature(for exports any): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> N S L�.'Ait►� 7'Vc-X4 -- O 1 13 1') <br /> Z <br /> TransporterPrin Name --Signaturd Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quaff ❑Type ❑Residue ❑Partial Rejection ❑FLA Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facilihr(or Generator) U.S.EPA ID Number <br /> .J <br /> Ca <br /> Facility's Phone: <br /> W 182.Signature o(Altemate Facility(or Generator) Math Day Year <br /> a <br /> z <br /> S219.Hazardous Waste Repot Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> Z <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Printedfryped Name Signature Month Day Year <br /> r� <br /> ..� o <br /> EPA Form 870022Rev.3-05 Previous editions are obso DESIGNATED FACILITY TO DESTINA N STATE IF REQUIRED <br /> 1)7297042/40712992 () <br />