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SSL SK 5t-1IP# eEeS&9-1� <br /> AC 0060946025x5 <br /> Please prin(or type.{Form designed for use on elite(12-pitch)typewriter. Form Approved OMB No.2950-x3q <br /> UNIFORM HAZARDOUS J1.C-aneqtorl0Num1be(, r/ 2.Pa 1 of 3 Em�ent seep , 4.Manifest frackin Number <br /> l00©:514 Cf? In 9l 1 C3WrU� �r�-1 FbNJ1006099602 g �/ <br /> WASTE MANIFEST SKS <br /> S.Gerc-r.a�tn+r's Name and Maifmg Address, g Gorwalor's Silo Address(if different than maJUng Wdrm) <br /> TC—X Lta I <br /> SYS TM INC U.S.EPA fo Nomk--r TX R04 30a 1205 <br /> 1:Trjias r 2 GYo�.i�n� pro U.S.EPA 11)Number <br /> �!B.ORS 041VIRONMEHTAL SERVICES INC MAD039322250 <br /> ff;t�: Faoq O':and Site Address CLEAN HARBORS OF WILMINGTON LLC U•S.EPA fU Numbor <br /> 1737 EAST VENNI STREET <br /> ;`,•'L,':;.r:.;. WILMINGTON , CA ` ID744 <br /> �r gEYi ;$,. 7�plfuri{i tdudltig Pieper Shy ng Name,Hazard Class,ID Number, 10.Containers 11'.Total 12,Unit <br /> 13.Waste Codes <br /> K. {�riY11 No. Type Quantity WtNol. <br /> ;H RItDBus WASTE, 5TlLIO OP7 � P 223 <br /> ly 1 rl• xriy1 <br /> -A <br /> in <br /> r 3 in <br /> Y-"•.:.+"�";� .,y.�.. y .rte;;... 1 <br /> TSO:WT CSG: t <br /> nrdsarsndAdda informs an <br /> :r .�r Y #1-•800-~468-1750 (5K / TFI) � 0•./ <br /> T7FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> R t %GERT1F1UT"Ift i homhy declare that the contents of this oonskynmonl are fully and accutatsry dosrnbed above by the proper shipping name,and are dirssiW,packaged, <br /> *,Wed,and are hi all los inproper condition for transport eccordin to applicable international and national mental regulations.If export shipment and I am the prima <br /> P� sP 9 PPI 9%r� !� Po �P ry <br /> ;. pr azntents of Ihis consignment conform to the terms of the attached EPA Ackn nt of Consent. <br /> ilwlrifuatJo t statemont idenKied in 40 CFR 262.21(a)(if I am a large quantitygenera or(e){dl ani a Is true. <br /> gnatu — h Day Year <br /> ' ❑ -/7- <br /> LIWVU.S. ❑Export from U.S. port Of <br /> ady) Data tea U"S: <br /> ;Sr 0 "l ii1 Ateb pl of Afataniats <br /> ...Nan Sfgnetiife �lanrfi pay Year <br /> /!� !1 -2- 1 L7 <br /> = Nain9 Sigrgluro Month Day Year <br /> r ti <br /> 1ati.'1) ie�m'f}cy fndiGallori$pace ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Numher. <br /> 18b,Alfemate 1=ae+iily(d l,crxralor) U.S.[PA ID Number <br /> 0 <br /> a aGllty's PUM: <br /> Tac,Sfgrraturc of Ali&nale Facrlily(or GeFWG;rj Month Day Year <br /> r— <br /> a 19.Rarardms Wasto Report Whagemwri Method Codes(i e.,codes for hazardous waste Ireelmorrf,dis sal,and t"ling systE.�ms) <br /> i n pc <br /> is 1 L3 1." 1 12, 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16p/ <br /> Nntedfrype 1 Nano+ Sfgnalure Month Day Year <br /> A 9v---�, ►� "til l�] <br /> EP[5('tfLrp 11 22 1 7 vious a Urins are abso!ete. DESIGNATED CILITY TO DESTINATION STATE(IF REQUIRED) <br />