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SSS SK SHIP0 232486,131x' <br /> Please.print or type. Form Approved.OMB No.2050-0039 <br /> 'UNIFORM HAZARDOUS1.Generator ID Number 2.Pae 1 of 3. m R s se Phu a 4.Manifest TrackingNumber <br /> WASTE MANIFEST :-00'7769571 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> AD SR - Bull= Sate ID SA - Bolden Sate <br /> 18503' West Stanford Rd Attn Samuel Mchenry 18501 Stanford Rd <br /> TRACY TRA � t:r CA X377 i ttn Lester`Saba <br /> Generattoor's Phonneep:m 9-3 88,2 1 T CY CA 55377...9705 <br /> SYSTEMS ISIS U.S.EPA ID Number 7 XROOOO8 l 20 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC: INC. MAD039MM50 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 419 OFF 1-80 <br /> 435-B84-8915 KNULLS v UT 8083 UTD991301748 <br /> Facility's Phone: <br /> 9a 9b.US.-DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol, <br /> 1. NO t ORA HAZARD0118 WASTE SOLIDS, (USED DM 7,00 P 352 <br /> o OIL AND ABSORBENTS) � <br /> UJ 2. <br /> LU <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD ff SM 8435-4443 A08@198 cse c <br /> 4H M ROI- OY S -468 .1760-CHASKITFI-Contra t retained by nenerator rconfors agency aL hpri y <br /> on initial transporter to add or substitute additional transporters on aengrAforls <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 anditational 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/ i <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 /> Gerator' Offeror's Printed/Typed Name Signature �' Month Day YaBfi'} <br /> 16.Inlet ational Shipments <br /> Pm El Import to U.S. ❑Export from U.S. Pori of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> T nsportert.rI Pnledffyped,'Na a lure Month Day Year <br /> o2y <br /> Priiransprntedlfypedame Sg�ture <br /> Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> r <br /> c� <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate 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 /> G 1. 2. 3. 4. <br /> F <br /> nated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ped Name Signature Month Day Year <br /> EPA For „87 0-22 v.h171 Prgvious editions are obsolete. GENERATOR'S INITIAL COPY <br /> 733 <br />