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tAtt( �m <br /> SSL SK SHIP � �� � (IIIIIIIIIIIIIIII �IIIIIII �III �II <br /> 0061 - 011146x6 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number CAL000 383 50 2. Pag1e 1 of 3 . EpeUq�ncyRpsponsg Php 4. Manifest Tracking Number <br /> WASTE MANIFEST 1 tSK1h 4bti 1 / bYJ ) 61 01114 SKS <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> City Of : Manteca <br /> 120 E Wetmore St <br /> MANTECA CA 95337 - 571217 <br /> Genaralor's Phone: 209 - a39 - 8450 <br /> 6. 49ffte,, lCg7tp�lYDlalneSYSTEMS INC U.S . EPA ID Number TXR000081 '205 <br /> r7. 'fFFu--'Il,Ils--ptetrinllrYY2 Company Nam U.S EPA ID Number ~ <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC . MAD039322250 ` <br /> B Des:jraledFacility Nam and Site Address CLEAN HARBORS SAN JOSE U,S. EPA ID Number <br /> 1021 BERRYESSn ROAD { <br /> SAN JOSE CA 9513 <br /> CAD059494 <br /> 408 - 441 -096c ' 310 <br /> Facility's Phone : <br /> ga 9b. U.S. DOT Desci ption (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packin Group (if any)) ffD <br /> Quaotalntity NlNoit13. Waste Codes <br /> t NON- RCRA HAZARDOUS WASTE , SOLIDS P 352 I <br /> o , ( WhSTE ABSORBENT AND DIESEL ) , .-NfAr ' <br /> W 2. <br /> So <br /> 3. <br /> 4. Wall <br /> 14. Special Handling Instructions and Additional Information TSD : SJ C125780 CSG p <br /> 24 HR EMERGENCY # i -800-468- 1760 ( SK / TFI ) AR <br /> AUTH AS " AGENT- FOR " BY GEN TO RETAIN LICENSED SUB CARRIERVZREk <br /> 15, GENERATOR'S/OFFEROR'S CERTIFICATION : I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeled/placarded, and are in al respects in proper condition for transport according to applicable international and national govemmentiA regulations . If export shipment and I am the Primary <br /> Exporter, I certfy that the contents of this Consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste min:mizabon statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (dl am a small quantity generator) is true. <br /> Generalor's/Offerol nled/Typed Name Signature Month Day Year <br /> <:T /;k <br /> 16, International rpments 11a i `1 1 <br /> ZImport to U.S. ❑ Export from U.S. entrylexit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> w17, Transporter Acknowledgment of Receipt of Materials <br /> T porter 1 Printed/Typed Na <br /> Sit gn Month Day Year <br /> f <br /> a or. <br /> QTrans Pnnled/Typed Name alone Month Day Year <br /> 2 <br /> 16. Discrepancy <br /> 18a . Discrepancy Indicaton Space ❑ Quantity ❑ Type <br /> ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: - <br /> 1Be. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generaior) <br /> Q Month Day Year <br /> z <br /> W19 . Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . 2. 3 P <br /> 4 ' <br /> 20. Designated racility Owner or Operator: Certficalion of receipt of hazardous ma rials covered by the manifest except as need in Item 1 <br /> Prin00, Sgna� M th Jl Y a <br /> I <br /> EP ) 81 822022 (Rev. 3-OS) Previouseditions are obsolete. DE AT FACILITY TO DESTINATION STATE IF REQUIRED <br /> 1 ) 810282a / " :, . 458 ( ) <br />