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SSL SK SHIP# 226367437 111111111 111 0063914713KS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number r 2.Page of 3. me RE -e P 4.Manifest Tracking Number WASTE MANIFEST CAL000312�06 - - �� 1006391471 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Les Schwab Tire Center 665 3260 W Grant Line Rd TRACY CA 95304-8427 Generator's Phone: 999-999-9999 s.TrbHF t I Y TpC�gA SYSTEMS INC U.S.EPA ID Number TX R000081205 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number 2247 S HIGHWAY 71 KIMBALL , NE £9145 308-235-4012 NED981723513 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. NON RCRA HAZARDOUS WASTE LIQUIDS DM /Sp P 343 I of , (GLYCOL ETHER, WATER),-.WA�11, � I ZUJ 2. 3 3. 4. 14.Special Handling Instructions and Additional Information TSD:KP 77728081 �1538888� I r•�Ci: G( tl fl f1/-(I �� IeL4 2� ` 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contrar_t retained by generator confers a ency authority on initial transporter to adsubstitute -+ 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, 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 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)(if I am a small quantity generator)is true. Generators/Offerors PrintedlTy a e i ture Month Day Year 16.Int ational Shipment z1:1Import to U.S. ElExport from .S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name � I r� Signature Month Day Year 0 J SlAW wGv9 v6 i g QTransporter 2 Printed! ame Signature Month Day Year �,►Sr � 11 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C3 1 2. J. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name re Month Day Ye EPAA$Z092 W ,�0Ogus editions are obsolete.' SIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)