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sS!_ SK SHIP# 228881546 <br /> 0069520875 KS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number Page 1 of 3. me�rgga ResRonse Phgng 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAI.01710'.t 'c_'0x -t3k'1L!t 4h,8-1. if•t7! �(S <br /> WASTE MANIFEST 006952087 n <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Les Schwab Tire Center 665 <br /> 3260 W Grant Line Rd �' b <br /> TRACY CA 95304-8427o V v ' <br /> Generator's Phone: 209-835-4029 <br /> 6.Tr ffj!�l ontp�V9M SYSTEMS INC U.S.EPA ID Number T X R@sZ 008 t 205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> P-247 9 HIGHWAY 71 <br /> KIMBALL , NE 69145 <br /> NED981723513 <br /> 308-235-4012 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> or 1. NON RCRA HAZARDOUS WASTE LIOUID:� DPS 343 <br /> of , (GLYCOL ETHER, WATER), #i'A-- <br /> 46 <br /> I t 50 <br /> iz 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD KP 80490293 LE 15385 <br /> t o" n �S ��3C <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers agency authori .y <br /> substitutean initial transpnrtpr tn add Or c ! p <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 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 <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 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Offer ri�tgdlT ed Name Signati+re1 Month Day Year <br /> G 7 �s <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: _ <br /> ? Transporter signature(for exports only): Date leaving U.S <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> UJI <br /> F- er 1 Printed/Typed Npme nature Month Day Year <br /> 0 <br /> o $ 1C,a <br /> Z ran s orter 2 Print ped Name <br /> n M Month Day , Year <br /> J <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Type Residue El Partial Rejection ❑Full Rejection <br /> ❑ ❑ <br /> Manifest Reference Number: <br /> JZ 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. T <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Mon <br /> ]CO Mc� Lf TMU Q ST-1 <br /> EPA Form 8700-22((Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)7879703/1325356 <br />