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SSL SK SHIP# 227481744 IIII�� III I'I�I I�I�F��I'�I� II <br /> $06776801 SKS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. me R e P 4.Manifest Tracking Number <br /> CA._01�1�1 I2. of: <br /> WASTE MANIFEST 006776801 SKS <br /> 5,Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> L_es Schwab Tire Center 665 <br /> 3860 W Grant Line Rd <br /> TRACY CA 95304-8427 <br /> Generator's Phone: 209-1335-4 029 <br /> 6.Tri sppr�1.Co{oanv[Ja ne SYSTEMS INC U.S.EPA ID Number T X R00008124Zt5 <br /> 7.Transporter I2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMF7NTAL SVC INC. MAn@39322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA I D Number <br /> 1021 8ERRYESSA ROAD <br /> SAN JOSE , CA 9:14:1 <br /> 408-441-0968 CAD059494.,i 0 <br /> Facility's Phone, <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Not 13.Waste Codes <br /> X 1. NA3077 HAZARDOUS WASTE, SOLID, N.O.S. DM b`U P D007 181 <br /> o , (CHRbMILJM), 9, Pr III <br /> a <br /> Z z. <br /> Lu <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSI)�SJ 790,1 542 9 LE 15385 C9G: <br /> 1iF_RG#171- I <br /> K)iio S-0 ass"s <br /> 24H EMERGtNCY#810-468-1760-CH/SK/TFI-Contract retained by generator con 11^ <br /> agency authori y <br /> on initial transporter to add or slibstitirte additional transporters on enerat0r`s behalf. <br /> 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, <br /> marked and Iabeledlplacarded,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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity general )is true. <br /> GeneratorslOfferors Printed/Type Name Signature Month Day Year <br /> .v o 1 ►s i5 <br /> 16.Int ational Shipm6nis <br /> H ❑Import to U.S. ❑Export from .S. Pod of entryexit: <br /> ? Transporter signature(for exports only): Data leaving U.S.: <br /> R 17.Transporter Acknowlsdgment of Receipt of Materials <br /> Transporter 1 PdntLd]Typed Name Signature Month Day Year <br /> kq A/ S I�j <br /> CL <br /> Z Tr �i tsdgyped NameSigna Month_ Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ouanuly ❑Type ❑Residue ❑Partial Rejectlon ❑Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S-EPA ID.Number <br /> a <br /> U <br /> 1 Facility's Phone'. <br /> w 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19,Hazardous Waste eport Management Method Codes(i e,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2 3, 4. <br /> 20.Designated Faciltyil or Operator Corti ration of r t of hazardous materials covered by the manifest except as n in m 18a <br /> PrintedlTyped Name ) ` Signature Mon <br /> EPj�olEaf. 114 ious Ilio solete.fL` DESIGNATED FACILITY TO EfA's e-MANIFEST SYSTEM <br />