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SSL` SKI <br /> IP# 2292384190 <br /> Please print or-type. Form Approved.OMB No.2050;0039 <br /> UNIF ."� 'HAZARDOUS` 1.Generatgr ID Number' 2.Page 1 of 3. me�g�p�y R sRo se P g 4,.ManifestTrackin Number �[ <br /> ASTE MANIFEST CAL00034687 1 "19YiiL1f� ~11y (� a ,° I`C� <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailingaddress) (;� <br /> ADESA — Golden late ADEM — Solden to ' <br /> 18501 beet Stanford Rd . Attn Samuel' Mchenry 18 1 Stamford.:; <br /> TRACY CA 95377 Attn Lester 000 <br /> Generator's Phone: a 4- 374 TRAC=Y CA 95377�97fb8 <br /> 6.Tr p4k- � U.S.EPA ID Number <br /> 1 M) . SYSTEMS } 'TXRO 81205 <br /> 7.Transporter 7 Company Name U.S.EPA ID Number <br /> MAN39322250 <br /> CLEAN HARBORS ENV SVC INC. <br /> 6.Designated Facillty Name and Site AddressCLEANHrARAORS OFUTTaivWLLCIbd U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW CA 9329& <br /> 661-7M-62M CAD980875876 <br /> Facility's Phone: S <br /> 9a. 9b.U.S.Q6 Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Cod <br /> HM and Packing Group(if any)) es <br /> No. Type Quantity Wt.Nol. <br /> TNOW ' "RC RA HAZARDOUS WASTES P 134 <br /> 0. LIGlU1S9 tDIESEL EXAUST FLUIDI' <br /> Z 2. <br /> LU <br /> c� <br /> 3: <br /> #f <br /> 4 <br /> 14.Special Handling Instructions andAdditional Infottftalion TSD s RL 80860005r A0 1lqt1 <br /> 4, <br /> 0 <br /> r:Eki EMERSENCY#80 176@—CH/SK/TEI�-Contract retained by generator confers agency A�thorri <br /> on <br /> initial r t: <br /> '15. GENERATGR'SIGFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and rat y 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 intern onal d nate nal 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 EPAAcknowledgment o nt. <br /> LFertify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or( (i am small quantity generator)is We. <br /> Offer Printed/TypedName. Signature Month Day Year <br /> r <br /> t ' <br /> 16.International Shipment <br /> ZEl Import'to U.S. ❑ExrtU.S. Port of entry/nit: <br /> Transporter signature(for.exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials h : <br /> 12 Tr p r 1 Printed/TyQed Nam nature Mdp h Da' Year <br /> :, <br /> a' <br /> ' I <br /> co <br /> rter 2 Printed lTyp e ., <br /> rgna ure <br /> Month ay Year, <br /> 18.Discrepancy - <br /> 18a.Discrepancy Indication Spacea'. <br /> ❑ Quaty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facilityor Generator <br /> ( ) U.S-EPA Ip Number <br /> J �rt <br /> tai . cility'sPhone: <br /> U- 18c.Signature of Alternate Facility(or Generator) MonthDay Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ <br /> 26.Designated Facility Owner or Operator:Certification of receipt oft azardous`matedals covered by the manifest except as noted in Item 18a' <br /> Printed/Typed Name „ Signature - i Month Day Year <br /> r c�gl� r <br /> j EPA�Forrm 8700-22(Rev.12-17)'Previous editions a .obsolete: DESIG fD FACILITY TO GENERATOR <br /> 547776/1787@85 <br /> i ,._ <br />