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SHIM <br /> Form Approved.OMB No.2050-0039 <br /> a I not or type 4,Manifest Tra_ckin Number �� <br /> 11.G enerator ID Number 2.Page of 3: me R e P �(,UNIFORM HAZARDOUSCALl�O03 , 8,7 l "'� �'" � <br /> *;J,a WASTE MANIFEST ; <br /> Generar s Name'and Mailing Address Generator's Site Address(if different than mailing address) <br /> 5. ADEtoSA - Golden Gate t4DESA Golden Cate <br /> 18591 West Stag ry 18i Stanford Rd <br /> Lard Rd. .. Attn Samuel Mchen <br /> CA 95377 Attn Lester Sabo <br /> TRACY ` h-5374 TRACY CA 95377 9708 <br /> Generator's Phone: amr <br /> U.S.EPA ID Number <br /> ,.:. <br /> I.TWOVER SYSTEMS INC T� f <br /> 7.Transporter 2 Company Name U.S.EPA ID NumberMAD03932225101 <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC- <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY PAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 419 I80 <br /> - <br /> ' KNOLLS v UT 84083 UTD99131745 <br /> 435-=664-a 91 <br /> 15 <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12 Unit 13.Waste Codes <br /> 9a: No.. Type Quantity Wl NOI. <br /> HM and Packing Group(if any)) <br /> NON RCRA HAZARDOUS WASTE SOLIDS1 (USED DM P 35�' <br /> 0 0I,� AND ABSORBENTS) <br /> ZLU <br /> CD <br /> 2: <br /> ,i <br /> t 3. <br /> 4. �• <br /> 14.Special Handling Instructions and Additional Information TCD GM 79693454,, ADE101198 <br /> \a <br /> 4H <br /> L <br /> E4H EMER NCY#6130-456-17f °CH/SK/TF'I-Contract retained by gI eratoi confers:; ency authbri y <br /> on inital<"transorter: to 'add or substitute additional tra frter� on enr^a d> •s bHalf <br /> 15. :GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desc' a bove by the proper shipping name,and are classified,packaged, <br /> Y <br /> marked,and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and n overnmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consjgnment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> ji <br /> I certify that the waste minimization statementidentified in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if I a all a tity generator)is true. Month Day Year <br /> - /Offeror s Pri /Typed Name Signature <br /> 14 1 <br /> ID <br /> 16.International Shipments Import to U.S., El Export from Port of enlrylexit <br /> ZDate leaving U.S.: <br /> Transporter signature(for exports only); <br /> ckt 17.Transporter Acknowledgment of Receipt Of Materials <br /> ansp er 1 PnntedfTyped Nan e <br /> Uj I ignature { Mdnnttthh Day Year <br /> Doth Day Year <br /> ra er2PrintediTyp ame M t <br /> 1 -D pa rr--tti' <br /> 18a DfscrepanG�,Indncation Spece ;Quantity? El <br /> Type' O Residue LJ Partial Refection Full ReJecBon <br /> Manifest:Reference Number. <br /> 18b.Alternate Facility(or Generator)' "U.S.EPA ID Number '- <br /> FacilitysPhone: y <br /> Da Year ' <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJI0 1 P 9t a 2.. �. 4 - <br /> 20.Designated Faa-fc�ility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ` Signature Month Day Year <br /> Printedffype <br /> me <br /> r7 <br /> E Y ESIGNATED FACILITY TO GENEdR <br /> EPA Form 8700 22 R �12-17 Previous editions are obsolete. <br /> 1)7645 E�32 , <br />