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SSL SK SHIP# 22910774 5 <br /> 007161579SKS <br /> Please print or type. Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2. 1 of 3. me R s erase 4.Manif7181579 S <br /> est Tracking Number + �� <br /> WASTE MANIFEST CAL000�43752 --��8-1 �� <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> City Of Tracy <br /> Bnyde Svctr 520 Tracy Bled <br /> TRACY CA 45376-0000 <br /> Generators Phone 209-831-4120 <br /> 6.TrrgWgygo Kffq SYSTEMS INC U.S.EPA ID Number TX ROO@061205 <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES,,, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL , NE_69145 <br /> 308-23!�7412 NED981723513 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if ai No. Type Quantity <br /> Wt, v. <br /> X 1• UN3175 WASTE SOLIDS CONTAINING DM P D018 352 <br /> o FLAMMAhLE LIQUID N.0 S. , (GASOLINE, <br /> BENZENE), 4. 1, P6 II Z <br /> Z 2. <br /> w <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD y KP 805433.41 C123277 CSG <br /> 1)ERG#133• ( q0M <br /> 24H EMERC,�NCY#800-468-1730–CH/SK/TEI–Contract retained by generato cclnferacy a��thari y <br /> on initial tr nsigorter to add or substituie additional tra— <br /> LI-L"a rt or , <br /> 15. GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping,y me,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable/inter to I and national governmental regtdatlans.If ' . ipment and I am the Primary <br /> Exporter,i certify that the contents of this consignment conform to the terms of the attached EPAAoknowledgf rase .I certify that the waste minimization statement identified in 40 CFR 2fi2.27(a){if 1 am a large quantity generato )(if I a small quantity generator)is true. <br /> Month Da Year <br /> eror's Print ffyped Name Sig �! Y <br /> . z tcl 1A ' <br /> 18.Intematlonal Shipments <br /> [= i ❑Impart to U.S. Export from U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T sp or PrintedTyp me nature Month Day Year <br /> O Y►� r f <br /> Z ransporter2PrintedfTyped m ure Month bay YeaQr <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> J ay <br /> V <br /> tai Facility's Phono:. <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes{Le.,codes for hazardous waste treatment,disposal,and recycling systems} <br /> LU 1. � 2• 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 /> Printed/Typed Namen, i Signature Month I Day Year <br /> EPAForm <br /> or 4�939�v 1171 Previous editions are obsolete. DES1G ATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />