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SSL SK SHIP#-&1aa5240;F <br /> 1NN;sa print or d Q 5 3 2 9 9 1 7 s k' s <br /> p type.(Form designed for use on elite(1�-Ruch}typewriter.) Form Approved.t7AAB No.Z€150-04;f9 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pag 1 of 3.E cY a Ph rre .AAa st T tag pl(u�mbepr q <br /> WASTE MANIFEST CAL.6t0$9117 1 �1190 p V 5 2 J C7 1 7 SKS <br /> 5.Generator's Name and MaingAddiress KiGenerator s Site Address(if different the mailing address) <br /> King <br /> Island Marina 0 W Eight Mile ted <br /> STOCKTON CA 95219-8708 <br /> Generator's Phone: �T7` tri� <br /> fi,TW Ctxn�i�. ER SYSTEMS' INC. U.S,EPA ID Nurnber 'j OO 8 05 <br /> t f h�Xi41���1 d�Kts.r <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Design FerdlityNameand 5�eAddress CLEAN HARBORS_SAN JOSE LLC U.S.EPA ID Number <br /> 1021 BERRYESSA (ROAD <br /> SAN ,I[l } CA 35 3.3,3 <br /> Facility's Phone: 408--441-096 CAaD@59494310 <br /> 9a, 9b.U.S.DOT Dascrtption(irduding Prater Shipping Name,Hatard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity wtivol. 13.Waste Codes <br /> lix —10 ADO <br /> NON RCRA HAZARDOUS ATE SOLIDS !3�# P ��� <br /> (RBsbRBENTS CONTAMINATED WITH OIL), .�'� � <br /> iu <br /> x 2. <br /> c� <br /> 3. <br /> i . <br /> 4, <br /> 14.Sped Handling Instructions endAddidonal Iribmatron 8 F 7 CSC <br /> 24 HR EMERGENCY #1 800--468~176iD (SK TEI) <br /> F <br /> 15. GENERATOR'SWfEROWS CERTIFIGAYION: I hereby declare that the cwntants ofthis consignment are fully and accurately deacriW above by the proper shipping name,and are classified,packaged, <br /> marked and tabetedlplacarded,and are m all raspeots in proper conditn for transport according to applicable internatkmaland national governmental regulations,If export shipment and f am the Primary <br /> exporter,I certify that the contarb of this oondgnment conform to the terms of ft atached EPAAcknowledgmeM of Consent, <br /> i that the waste minfmization statemsn iderged in 40 OFR 262.27(a)M I am a large quantity generator)or(b)(if I am a small antlty generator)is true. <br /> rc <br /> r inted/iyped Nw" 09 Day xear <br /> _r IV,Internavonal brilpmetm <br /> ❑Impart to A. t Export from U.S. Port of entryll'. JL V <br /> Transporter signature(for exports only): Dale leavkrg U.S.: <br /> ui 17.Trans Acd(noWiedgment of Receipt of Materiats <br /> Transp r 1 rintedlTypad ryame 5ignatur Month Day Year <br /> W. Transporter 2 Printed]Typed Name Sglnature - Month pay Year <br /> 4; <br /> 18.Discrepancy <br /> 1 Ba.Dismpancy indicafion Space ❑ warmy ❑TypB ❑Residue Partlat Roectian tT_i Full Re0on <br /> Raferenber: <br /> tBb.Alternate Facility(or Generator) Manifest de Num <br /> U.S.EPA ID Number <br /> U <br /> --ac4itys Phone: <br /> LU 18c.Signature of Attemate Facility(or Generator) Month flay Year <br /> Q <br /> Z <br /> razardouswaste Re rt Maponagement Metfrod Codes(I.e.,codes for hazardous waste ireatmarrt,disposal,and recycling systems) <br /> L j 1 2. 3. 4. <br /> 0.Dasig ed Fadi Owner or Operator;Certitica n of receipt of hazaadws materials covered by the manliest exceptnoted in ItBLA 18a <br /> f3rin Neme t Signature <br /> CA N IDS Y" It <br /> E AIV 2At��1 405} Previous editions are obsolete. SIGNATED FACILIT 'TO D �WAPTINSTAT {1F>�EQUIR D) <br />