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SSL SK" SHIP# 226375037 111111111 I,IIII�'�IIII�II111 0069416068 KB Please print or type.(Form designed for use on elite(12-pitch}typewriter.) Form Approved.OMB N0.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Pa of me Re e P 4.Manifest Traeki Number CAL000427958 -� - �-gym 0 0 6 3 16 0 6 SKS WASTE MANIFEST 5.Generator's Name and Mailin Address Generators Site Address to different than mailing address) P&B Intermor�al 1000 E Roth Road FRENCH CAMP CA 95231-0000 Generators Phone: 562-822-1234 s.Tr�ft*2RL SYSTEMS INC U.S.EPA ID Number TXROOOO81205 7.TraCnspEeArNCompAanYBORS ENVIRONMENTAL SVC INC, U.S.EPA IDNumbe I.. !i ti MAD039322250 8,Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number 1021 BERRYESSA ROAD Facility's Phone: SAN JOSE , CA 95133 408-441-0962 CAD059494310 9a, 9b.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total al 72.UnN M and Packing Group any)) No. Type Quanaal Wt.Unt 13.Waste Codes 1. NON RCRA HAZARDOUS WASTE SOLIDS DM P 223 o (DEBRIS, PETROLEUM HYDROCARBONS) W z 2. w 3. 4, 14.Special Handling Instructions and Additional Information— TSD-SJ 7781459,4 PB 1206 ' CS(3. 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract r aired by g4t�ratvrl ynrs agge�authori y on initial transporter to add or substitute addit al trans arters an eneratorss behalf. 15. GENERATORWOFFEROR'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 labeledlpecarded,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 EPAAcknowledgment of Consent. I I certify that the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity generator)or (if I am a small quantity generator)is true. Generators/Offerors PHy Name Si natirre 9 Month Day Year D vc� 'i 115 p9 010 !S" —t 16.International Shipments I-- ❑Import to U.S. ❑Expod from Port of entrylexA: K Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter AcknoWledgment of Receipt of Materials Transporter 1 PrintedITyped NarOe-e^u� r ` Signature /� , Month Day Year , CIL (13 C16 el Transporter 2PrntetlfTy me ' SignatureMonth Day Year F- f� 18.Discrepancy 18a.Discrepancy Indication Space ❑Quantity ❑T e yP ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Atemate Facility(or Generator) J U.S.EPA ID Number U U,- Facility's Phone: w 18c.Signature of Allemate Facility(or Generator) Month Day Year Q z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 ///W 1 2. 3 4. 20.Designated Facility Pmer or Operator.Cortificittion of receipt of us materials covered by flO manifest e—A noted in m Printed lTyped Name jfSignatu Mon Day Year - tz EPy8 ev.3.0 P v use ibonsareohsolete. SIGNATED FACT TO D [NATION STATE REQUIRED) 1) 12758311484