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SSL SK SHIP# 226826485 <br /> Please print or type. 0 0 6 6 5 7 4 1117 S K 6 i <br /> 1.Generator ID Number Form Approved OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3. m�,rH�ricy R s se P 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000043752 1 —td�oK! �Fgg 1X0 006687417 <br /> �^� � � ��� <br /> 5.Generators Name and Mailing Address Generators Site Address(if diftamnt than mailing address)b <br /> City Qf Tracy <br /> B, L Svii 520 Tracy Blvd <br /> RRAA 209-831-412@ CA 95376-006@ <br /> one: <br /> Generator's Ph <br /> 6.T(gcnnrtar .1.`prr�fi�pan�j SYSTEMS INC U.S.EPA ID Number <br /> hjporte �r pan TXR000081205 <br /> Z Transporter,Company Name <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. U.S.EPA ID Number <br /> 8 Design atedFacility Name and Site Address CLEAN HARBORS SAN JOSE <br /> U.S.EPA ID Number MAD039322250 <br /> 1021 BERRYESSA ROAD <br /> 408-441-0962 SAN JOSE , CA 95133 <br /> Facility's Phone: CAD10159494310 <br /> ga, gb.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM a packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> c NBNE, NON RCRA HAZARDOUS WASTE SOLIDS, DM S P 352 <br /> (OIL, DIRT AND SAND),-NAA-,&� <br /> w <br /> M 2. <br /> 3, <br /> 4. <br /> 4,Special Handling Instructions and Additional linformation T- <br /> TSD.SJ 78302014 C123277 <br /> !�f� CSS:Il ��,, n <br /> 24H-EMERGENCY#8@0-468-1760-CH/SKITFI-Contract retained by generator confess a e L� <br /> In ni a a o f o r s s y authi aenpratti hi.1 i y <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION:Thereby declarethat the contents of this consignment are fully and accurately descin above tthepropef. <br /> r shi m name,aMareclassified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intematienal and national govemmeny t repropers 6exp name,rt an are d am the Pdmary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator or if <br /> mall quantity g erator)is true. <br /> Geennerator's/Offerors P2ntadflryped Name A Signat e <br /> v f✓�-1WNQ. <br /> Month Day Year <br /> ,j 16.Intemation@I Shipments <br /> H it O <br /> H ❑Import to U.S. ❑Export from U.S. no rcftxit. <br /> ? Transporter signature(for exports only): <br /> D take ing U. <br /> LU <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintetlRyped Name :5, A m� 0q Lon Signature 1 ^ Y <br /> 0. it .C`� �,�,/`.� M n Da Y <br /> a `� o Z. 'it- <br /> Thai Tran 2 PrintecifTyp..Name 1 Signature <br /> K / Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type YP ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manrfest Reference Number: <br /> U.S.EPA ID Number <br /> U <br /> . Facility's Phone, <br /> C11 18c.Signature of Alternate Faallty(or Generator) <br /> Q Month Day Year <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> ILLI 2. 3. <br /> 4. <br /> 20.Designated Facility wrier Operator:Certificat n of recei zardous ri covered by the manifestexcept a neled in Item 18a <br /> Printedf7yipedName Signature M D <br /> EPS Fo�rr7o6-22 - P6rviouseditionsare rete. EPA's a-M IF <br /> DESIGNATED FACILITY TO 5Y TEM <br />