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Sst SK S I P# 225442512 V <br /> Please print or type.(Form designed for use on elite(12 pitch)typewriter.) 0.06520479SKStForm Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin <br /> WASTE MANIFEST �1i�004:�75 - - F, ~11 .0065M79 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> City Of Ttx cy <br /> Bcsyde Svctr 520 Tr roc Blvd <br /> TRACY CA 95375-0000 <br /> Generator's Phone: 209-831-4120 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS INC TXROOOOS1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD0.393 2250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS <br /> ARBORS ENVIRONMENTAL <br /> NVqROYMEN AL SERVICES, <br /> ERYICC3, IN <br /> U.S.EPA ID Number <br /> 247 S HIGHWAY 71 <br /> KIMBALL , NE 591.4 <br /> Facility's Phone: 308-235--4012 1NFD981723513 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM ani Packing Group(if an13.Waste Codes <br /> No. Type Quantity W1.NDi. <br /> 1. <br /> XUN3175 WASTE SOLIDS CONTAINING � DM P DOI6 -52 <br /> of FLAMMC itLE LIQUID N.0 S. , (GASOLINE, <br /> BENZENE), 4. 1, P II <br /> 2. <br /> w <br /> to <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions and Additional Information <br /> TS)3:KP 76949927 CI2377 <br /> 1)ERG# � <br /> 24 HR 1=M1�E�F.�FNC;Y #!-600-468--1760 (CFi ! SK f '3"Ft) <br /> Si j{ <br /> 15. NE T 'SIOF R R'S CER 1 CAT1 N: I hereby declare that the contents o t is consignment are fully an accurately described a ve y the proper shipping name,and are classlfred,packaged, <br /> marked and€abeledfplacarded,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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or (if I am a quantity generator)is true. <br /> Generators/Offeroes PrintedlTyped Name Sign re Month Day Year <br /> 12AMIZ LAS ?.( 09, <br /> -j 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of enirylexit: <br /> Transporter signature(for exports Dniy): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> QTransporter 1 PrintedlTyped,�N-a�me�r,, `1 Signature Month Day Year <br /> 0. <br /> `�H /V ( / <br /> co <br /> Q r2 Printedrryped Name Signa Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> .r <br /> U <br /> LL Facility's Phone: <br /> w 1B Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> za 19.Hazardous Waste 4AaReport Management Method Codes(I e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 <br /> ".. , 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 18a <br /> PrintedlTyped Name Signature Month Day Ye r <br /> EPA Form 8700-22(Rev.3-05) revious editionsa soete. D GN ED FAC iTO DESTINATION STATE(IF REQUIRED) <br /> 1)8047939y15465E9 <br />