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SSL SK SHIP# 223787485 III(III(III�II)III�I(I�I II III II I SII <br /> 0 0 6 1 9 3 4 2 7 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 13.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST CAL000043752 1 1-800-468-1760 00 <br /> 61 3427 $K$ <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> City Of Tracy <br /> Bayde Svctr 520 Tracy Blvd <br /> TRACY CA 95376-0000 <br /> Generators Phone: 209-831-4120 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS INC TXROOOOB1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> Facility's Phone: 661-762-6200 CAD980675276 <br /> 9a 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 11401 NON-RCRA HAZARDOUS WASTE, DM P 331 <br /> 0 LIQUIDS, (ASPHALT EMULSION), 40A V`- <br /> Z 2. <br /> UJ <br /> 3. <br /> 4. <br /> { <br /> 14.Special Handling Instructions and Additional Information TSD:BL 75152886 C I23277 CSG: <br /> 24 HR EMERGENCY #1r800-468-1760 (SK / TFI) 1 -1bey -) <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATI N: I hereby declare that the contents o this consignment Mau ly and accurately describe above y the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 EPA Acknowledgment 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(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> (-TANK Qr-011404 ItoZ!o 11-7 <br /> J 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> oc Transporter 1 Printed/Typed Name Signature Month Day Year <br /> EU E UU,1q� - 10 Z(o <br /> Z Transporter 2 Pdnted(Typed Name Signature Month Da Ye <br /> acy r f,- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type 1:1 Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> 1 Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. � 2. 3. 4. <br /> / <br /> 20.Designated Facility 0 er Operator:Certificatiorfof rete' of hazardo aerials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed NameSignature M h Year Xl�t�Axll . - <br /> EPA Form 8700- (Rev.3-05) Previous editions are dlba6lete. DESIGNATED FACILITY TO DESTINATION STATE(IF REOU ED) <br /> 1)8047286/1546592 <br />