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• [ SSL SK SHIP# 232065793 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAD981970825 1""'geJof 3. m RgS kkse Pr�,� 4 Hfanifesi Tracking Number <br /> WASTE MANIFESTlE�R) 006951693 SKS <br /> 5.Generator's Name and Mailing Address ne + 10.jd i rKQX� rr illing address) <br /> City Of Lodi—Eud <br /> 1331 S Ham Ln Attn Thomas Dean , <br /> LOD I CA 95242-0000 8 M0 <br /> �.. generator's Phone: 209-333-6762 T <br /> w 6.TrgWj� o fCL� SYSTEMS INC " = S•EPT ID Number <br /> TXR000081205 <br /> T Transpgrter 2 Company Name U-S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designaled Facifly Name and Site Address CLEAN HARBORS OF WILMINGTON � U.S.EPA ID Numher <br /> 1737 EAST DENNI STREET <br /> FaClllty's Phone: <br /> WILMINGTON , CA 90744 <br /> 310-835--9998 CAD044429835 <br /> _ <br /> 9E, 9.b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> Hid and; king Group(if any)) 13,Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1NON RCRA HAZARDOUS WASTE LIQUIDS DM P 221 <br /> 0 4, MINERAL OIL), �,QO <br /> 9 <br /> Z 2, <br /> uu <br /> 0 <br /> 3. <br /> a. <br /> 14:Special Handling Inslructlons end Additional fnformatioii Y" TSD:W I 83904893 C135503 <br /> av <br /> 24H EMERGENCY#800--468-1760--CH/SKITFI-Contract retained by generator confers anency authori y <br /> an initial ttgnsporter to add or substitute additional tcansWorters n neneriflirls. behalf. <br /> 15, GENERATQR'SIOFFEROR'S CERTIFICATTON: 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 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 Consent. <br /> cerlily that the waste minimization statement identified in 40 CFR 262.27(a)(91 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Genera{orslDReud PrmtedrrywNam. Signature Month Day Year <br /> ,.,j 16.International Shipmepts <br /> IL-_ ❑Import to U-S. ❑Export from U. . Port of entrylexit: <br /> ? Transparter signature(for exports only): Date leaving U.S.: <br /> W 17,TransportarAcknowledgment of Receipt of Materials <br /> LLJ <br /> Tra rtar 1 PrntedlTyped Name F Signature Month pay Year <br /> d <br /> Q 0 W CA , a <br /> M TL% art PrinledFTyped me Signatu Month Day Year <br /> 18.Diwepancy <br /> 18a'.Discrepancy!lndication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection EJ Full Rejection <br /> a <br /> Manifest Reference Number, <br /> I6b.Allninate Foolllty(or Generalor) U.S.EPA ID Number <br /> U <br /> Li- Facility's Phone; <br /> LU 1 Sc.Signature of Allernals Fadllty(or Generator) Month Day Year <br /> Q <br /> 2 <br /> C719.Hazardous Waste Report Managemsm Method Codes(i.e.,codes for hazardous waste'ireatrriant dispuaf,and reoycling systems) <br /> 11 <br /> m <br /> 0 1- 2. 7 4. <br /> 20,Designated Facility Owner or Operatar.Certification of receipt of hazardous materials covered by the manifeseexcept as noted in Item 18a <br /> PrfnledlTyped fume �,.yy Sign2ture Month Day Year <br /> U� �-h GSL Y-% '' <br /> EPA Form 8700-22Rev.12-17) Previous editions are oholateQ UbESIGNATED FACILITY TO GENERATOR <br /> 1)772913( /1085468 <br />