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SSL SK SHIP# 231267091 1I11Il11II1 1111IN1I <br /> 0074766963KS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.P*q.lmegN R42i1to4.Manifest <br /> anifest Tracking Number <br /> uumbbeer <br /> WASTE MANIFEST CAL000312206 bffe 00747669 <br /> c v„V <br /> 5.Generator's Name and Melly Address Generato's Site Address(if different than mailing address) <br /> Les Schwab ire Center 665 <br /> 3260 W Grant Line Rd <br /> TRACY CA 95304-8427 <br /> Generator's Phone: 209--835-4029 <br /> e.TrggscoWrGpmpafty&'q <br /> � SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Compan Name U.S.EPA ID Number <br /> CLEAN HA f BORS ENV SVC INC. MAD039322250 <br /> B.Designated Facility Name and StleAddress CLEAN HARBORS SAN .LOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN 705E , CA 95133 <br /> 408-441-0%2 CAD059494310 <br /> Facility's Phone: <br /> 9a 91).U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, t0.Containers 11,Total 12.Unit 13.Waste Godes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> X 1, NA3077 HAZARDOUS WASTE, SOLID, N.O.S. ( DM too P D00 181 <br /> o , (CHRbMIUM), 9, PG III f <br /> �a <br /> z 2. <br /> ce <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD r SJ 83012872 LE15385 CSG; <br /> 1)ERG#171. a W�?r <br /> 24H EMERG�NCY#800-468-1760-CH/SK/TF1-Contract retained by generator confers agge cy authari y <br /> on initial transporter to add or substitute additional transporters on enerator's behalf. <br /> 15. GENERATOR'SfOFFEROWS CERTIFICATION:1 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 labelediplacarded,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 lire terms of the attached EPAAdmow4edgment of Consent. <br /> I oertify that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(III am a small quantity generator)is true. <br /> Generators/Offeroes nb%VTyped Name Signature Month Day Year , <br /> irJ�� ji <br /> 5 IS <br /> Z.� <br /> 16.International ShipmeAtl <br /> I= ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TmnspoRerAcknowledgmenIofReceipt ofMaterials <br /> Transporter 1 Pri Ry Name Signature Month Day Year <br /> 0 0, I 16 )U !� <br /> CL <br /> Z Transporter 2 Printedrryped Name S' ate N Mortih Day Year <br /> 1 <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space * ❑T ❑ ❑Full Re' <br /> ❑Quan' Type ❑Residue Partial Rejection lection i <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facilitys Phone: <br /> w1 8c.Signature ofAttemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste headrrenI,disposal,and recycling systems) <br /> LU� 1 � Y� � � 3. 4. <br /> 20.Designated Facility Owner or Operator.Cedihcafion of receipt of hazardous materials covered by the manifest ex t as noted in Item iaa <br /> Prin arae , & sign atum MDay, WeW <br /> IS I?j V <br /> EP1igMefi? ,Jt l7) [@Vouseditonsareobsolete. DESIGNATED FACILITY se-MANIFEST SYSTEM <br />