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SSL SK SHIP# 23065IB39 <br /> 0072755765 K5 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number CALOOM3752 2,PaL4f 3.Eme Respop5e Phopa� 4.Manifest Tracking Number �� <br /> WASTE MANIFEST 1 OHO—'1U0 ]!O <br /> 5.Genendoes Name and Mailing Address Generators Site Address(if different than mailing address) <br /> City Of Tracy <br /> BoYd�e SVC <br /> 520 Tracy Blvd <br /> TRRCY CA 95371,-00210 <br /> Generators Phene: 209-831-4120 <br /> 6.Tr3gsppdB[1CrxnDariy SYSTEMS INC U.S.EPA ID Number TXRO00081205 <br /> 7.Transporter I2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> B.Designated FadlityName and Site Address CLEAN HARBORS ARAGONITE, LLC U.S.EPA ID Number <br /> 11600 NORTH APTUS ROAD <br /> ARAGONITE ! UT 84024 <br /> UTD981552177 <br /> 435-884-8100 <br /> Facility's Phone: <br /> ga 91h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity M.lvol. <br /> X 1 UN3175 WASTE SOLIDS CONTAINING DM P DOI 352 <br /> o FLAM TILE LIQUID N.O.S., 26ASOLINE, <br /> ~aa, BENZENE), 4.1, R II sJC� <br /> LU 2. <br /> w <br /> c9 <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information TSD-.AG 82359091 Cl27 <br /> 1)ERG#133• 0Lai 7 <br /> 24H EMERg&CY#800-468-1760—CH/SK/TFI—Contract retained by generator confers a ency authori y <br /> on initial transporter to add or substitute additional trans arters on enera�ar's behalf. <br /> 15. GENERATOR'SIOFFEROR'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, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national mental regulations.It expert shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)' a g or)is true. <br /> emrs PnntedlTy me Signature Month Day Year <br /> Ej "`� = �✓ f 70 <br /> j 16.International Shipments <br /> F ❑import to U.S. ❑Export from Port of ent y(exi1: <br /> ? Transporter signature(for exports only): Date I .S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> nsport 1 Pnntedl yped S' re - . Month Day Year <br /> r, 16 �� <br /> Z n rter2Printe ame 11lignauum Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity T . ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemale Facility(or Generator)C 1e 11 �,3,„r {� fl.ry U.S.EPA ID Number <br /> J Q � Wi 1 Y�1C[�kj'� Y �/J O <br /> Facility's Phone: R � Y,` S` 1 Sr7 �� •d -� V 'l+3 O <br /> w 18c.Signature of Alternate Facility(or Generator) 1 Month Day Year <br /> a <br /> z <br /> H19,Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2, <br /> yo <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous ma rials covered by the manifest except as atetl in Item 18a <br /> Pnntedrty e �� � Signature Month_ qa ry Year <br /> EPI0 8740-22(R� g1ff aiouseditionsareobsolete. DESIGNAT'-=D FACILITY TO EPA's e-MANIFEST SYSTEM <br />