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SSL SK SHIP# 228634703 RECEIVED BY SJCEHD: <br /> Please print Dr7/16/2019 <br /> bpi Form Approved 0648 No 2050-0039 <br /> UNIFrkM HAZARDOUS t GeneratorID Number CAL000264132 2 Page 1 of 3 m_ R _F 4.Manjest Tra kiSN1�28 <br /> WASTE MANIFEST 1 1 —�1�� �"f�s0 O O 6 9 4� SKS <br /> 5 Gereialo;s Nameano Yaihng AddressVJ�J <br /> 7-11 Materials Generators Site Address of different than mad ng address) <br /> 2714 Stagecoach Dr <br /> STOCKTON CA 95215-0000 <br /> Gereralor'sPhone 209-853-1283 <br /> SYSTEMS INC US EPA ID Number T X00O81205 <br /> i Transporter 2 Com an Name <br /> CLEAN H�I�BORS ENVIRONMENTAL SVC INC. US EPA ID Number <br /> Designated Facmty Name and Site Address MAD039322250 <br /> CLEAN HARBOR5 SAN JOSE US EPA ID Numbe; <br /> 1021 BERRYESSA ROAD <br /> 408-441-0962 SAN JOSE , CA 95133 <br /> Facilays Phone CAD059494310 <br /> 9a 9b U S DOT Description(IndWing Proper Shipping Name Hazard Class,ID Number, <br /> HM and Paclung Group pf any)) 10 Containers 11 Total 12 Unit <br /> i( Jf No Type Quantity Wt Na 13 Waste Codes <br /> 1NON RCRA HAZARDOUS WASTE SOLIDS PM P 223 <br /> Cr (DEBRIS, PETROLEUM HYDROCARBONS] <br /> a ✓ <br /> U.1 <br /> z <br /> w <br /> c7 <br /> 14 Spatial Handling Inst uctrons and Additional InformationTSD:.SJ 80234551 7110178 CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers a ency authori y <br /> on initial transporter to add or substitute additional transporters on enerNor' s behalf. <br /> GENERATOR'SlOFFEROR'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 /> man,Ly7 and IabeleG p:acarded and are it al!respects in proper wridit for"nsport 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 lbert s othhe attached EPA Acknowledgment of Consent <br /> I certify,that the waste minimization statement identified In 40 CFR 26227M pf I am a large quantity generator)or(b) <br /> _it mall quant a atorl is <br /> Generator's' s Printed-T a Signature M Day Ye <br /> 16 International Shipments ❑ <br /> P- Import to U S. ❑Export from U Sof en ie>vI <br /> K Transporter signature(for exports onlyl ate leaving U S <br /> it w 17,Trans iter Acknowledgment of Receipt of Materials <br /> aTrans <br /> 1 PnntedrTypeame V V' w i igna:urey <br /> N 2 P Name <br /> Q S natur Mo th Day Year <br /> Zq In <br /> 18 Discrepancy I <br /> 18a Discrepancy Indicabon Space El <br /> Quantity ❑Type ❑Residue ❑Partial Rejection t ❑Full Rejection <br /> Manifest Reference Number <br /> 18b Altemate Facility(or Generator) US EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone <br /> W 18c Signature of Altemate Facility(or Generator) Month Day eG, <br /> a <br /> Z <br /> 12 19 Hazardous Waste Report Management Method Codes(i e codes for hazardous waste treatment,disposal,and recycling systems) <br /> N <br /> D 1 2 3- 4 <br /> 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest ex pas noted in Item 18a <br /> Prin Name r Signature / Moryh Day Year <br /> EPA�opn,B & LFjv112t7�_P yous editions are obsolete. DESIGNAV KCILITY TO GENERATOR <br />