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SSL Sys SHIP# 230406911 Illlllll IN I 1111111111111111111111 <br /> OQ72763511111K8 <br /> Please print or type. Form 4pro,OMB No.245M039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2. 1 2Page 1 of - "fit '1 tf�3.E R s e P,h� .Alan 1 Track ng umber <br /> WASTE MANIFEST CALO$0346875 � , 10072 7 6 3 51 SKS <br /> 5.Generator's Name and Melling Address Generator's Site Address(If diffeerent than mailing address) <br /> ADESA - Golden Sate ADESA - Golden gate <br /> 18501 Test Stanford Rd Attn Samuel Mchenry 18501 Stanford Rd <br /> TRACY CA 95377 Attn Lester Sabo <br /> Generator'sPthone; 209-839-3882 TRACY CA 95377-9708 <br /> 6.T ��ornpAn hg SYSTEMS INC U.S.EPA ID Number TX ROOOO81205 <br /> 7.Transporter 2 Company�Naam1�e1 U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and SiteAddress CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> FadN s Phone; SAN JOSE , CA 95133 <br /> 408-441-0%2 SAN <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Paddng Group(If any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 1 NON-RCRA HAZARDOUS WASTE, SOLID AM P 223 <br /> o (OIL FILTERS) <br /> 9 1 t 5 <br /> Z 2, <br /> LLI <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TSD:SJ SP 105100 AD80198 CSG <br /> '-J- <br /> 24H EMERGENCY4#800-468-1760-CH/SK/TEI-Contract retained by generator confers a envy authori } <br /> on initial transporter to add or-substitute ad 'tional rans ort rs ener r' half. <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:.1 hereby declare that the contents of this consignment are fusty and accurately descdbad above by the proper;hipping name,and are classified,"packaged, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable intemational 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 Co <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 a s quantity generator)is true. <br /> e. <br /> Name Signatu Month• Day Year <br /> —1 16.International Shipments <br /> ❑Import to A. ❑Expo . , Port ofentry/exh: <br /> Transporter signature(for exports only): Date leaving U. <br /> Ir 17.Transporter AdonaNedgment of Receipt of Materials <br /> PVSWer 1 Pdnteda Wd Name ignature <br /> � Month � Day Year. <br /> C43 Z aIra <br /> Z I h=!� <br /> Trans r 2 Print yped Name ` e Month° Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ��•--�� <br /> Quantity ❑Type ❑Residue LJ ParBal Rejection ❑Eull Rejedbn <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number <br /> J <br /> W Facilitys Phone: <br /> 180.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes r e codes for hazardous waste treatment,disposal,rn 9 (•• •, and recycling systems) <br /> d 1. 2• 3. 4, <br /> LL-t( J . 1011% 7 - 31 1 WOOD <br /> 20.Designated Facility N&or ator. of r t azardous materials covered by the manifest except 18a <br /> PruntedrTyped Name ignatu <br /> EPA q Form/8.r70'y0.22(�ReJ . Pvid s editions o oiete. DESIGNATED FACILITY TO EPA's e•M IF T YSTEM <br /> a)761 G.�L��L�J! 156777 <br />