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SSL SK SHIP# 225311780 Please print or type, (Form designed for use on elite 12- ' 0 0 ( pitch) ewntec) O O t5 5 Q 5 7 S S K S Form A UNIFORM HAZARDOUS :Address nerator ID Number 2, Page 1 of 3. Emergency Response Phone 4, Manifest Tracking kumberroved. OMB N0. 2050-0039 WASTE MANIFEST CAL000299414 1 1 -800-468- 1750006520575 O 5 O C �r c v � 5. Generators Name and Mailing Generator's Sits Address (If different than mailing address) J l J !� Chrzsp CO 1001 Stakes Ave STOCKTON CA 95215-4023 Generators Phone: 209-94 --3038 III JIM JIM 11 1 JIM 11 1 JIM 11111 11 1 li�0. Transporter 1 Company Name SAFETY-KLEEN SYSTEMS INC U.S. EPA ID Number 7. Transporter 2 Company Name TX R000081205 CLEAN HARBORS ENVIRONMENTAL SVC INC . U.S. EPAID Number 8. Designated Facility Name and Site Address MAD039322250 CLEAN HARBORS SAN JOSE U,S. EPA IDNumber . 1021 BERRYESSA ROAD SAN JOSE , CA 95133 ( , . Fadl s "one: 408-441 0962 CAD055494 10 ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, HM and Packing Group (if any)y 10. Containers 11 . Total 12. Unit No. Type Quantity WI./Vol, 13. Waste Codes a 1 NOW NON RCRA HAZARDOUS WASTE SOLIDS , DM P ( DEMIS , PETROLEUM DISTILLATES ) , -t+644- / P 223 F4. : 14. Special Handling Instructions and Additional Information TSD : SJ 76719884 CH40434 CSG : 24 HR EMERGENCY # 1 ;800-468- 1760 ( CH / SK ~ / TFI ) L6A01L4qI.� [_[, 11 1111 l� lin PAtilrITIIIIIIIIIIIIIIIA 15. GE ERA OR'SIOF ER R'S CERTIF CATI N: I hereby declare that the contents of this consignment are fully an accurate y described a ve by a proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in alt respects in proper condition for transport according to applicable intemadonaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (III am a small quantity generator) is true. Gene rator'slofferoes Printedrlyped Namo Signature JilMonth Day Year 16. International Shipments ❑ Impdit to U.S. ❑ Export from U.S. Z Transporter signature (for exports onty): Port of entry/exit 17. TransporterAcknowledgment of Receipt of Materials Date leaving U.S.: T er 1 P It yped Na Mon Year CL 1 j Q Transporter 2 riot yped Name Signature 0111111 I'll Jill Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection 18b. Alternate Facility (or Generator) Manifest Reference Number: U.S. EPA ID Number U LL Fadlity's Phone: 18c. Signature of Alternate Facility (or Generator) °ZMonth Day Year z 19. Hazardous W s Report Management Method Codes (t.e,, codes for hazardous waste treatment, disposal, and recycling systems) LU 1. 29 13 4. 20, Designated Fad comer or ereto Certificat f receipt of h ardous materials covered by the manifest axes as not Item 16e Prinle yped Name Signature E � a EPA Forrn 6700-22 (Re . - 5) Previous el sole e. D 1 ) 7429310 / 731681 ATED F V TO DESTINATION STAT (IF REQUIRED) i - - - -