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t <br /> S#i SHIP# 231942097 <br /> Please print or type. Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Numher 2.Page 1 of 3. me R§seg P}r� 4.Manifest Troeking Number �� i <br /> WASTE MANIFEST CAL0Qp0014763 1 ^di010-46d-1! <br /> 5.Generators Name and Mailing Address Generators Sae Address(if different than mailing address) <br /> Calaveras Materials Inc. <br /> 1945 Lathrop Rd <br /> t_ATHR13P CA 95330-0000 <br /> Generator's Phone: 555-469-'3838 <br /> s.7T�pspffierpoorlTCTo�L�t.t►tf SYSTEMS INC _ U.S.EPAID Number TXR00fD081205 <br /> 7.Tr`.alnssp2 Company Name U.S.EPA ID Number <br /> CLEAN HAR13ORS ENV SVC INC. MAD039322250 <br /> B.Designated Facility Name and Site Address CLEAN HARBORS SRN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 CAD0594943I0 <br /> 408-441-0962 <br /> Facilitys Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper5hipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WtNol. <br /> 1 NON-RCRA HAZARDOUS WASTE SOLID. 1 DM 7� p 223 <br /> o (DRAINED AND UNDRAINED OIL FILTERS), / 1 <br /> USED OIL FILTERS CONTAINING USED OIL <br /> LU <br /> 2. <br /> w <br /> [7 <br /> 3. <br /> 4 <br /> i <br /> 14.Special Handling lnsmrchuns and Additional Information TSD:SJ 83775829 CA67265 CSG. i <br /> 24H E�iERIsEIY#800-468 1750-CHiS�(iTFI-Contract retained by generator confers a envy authori y <br /> on iDitial tran-sporter to add or StAh5titUttill' and <br /> or <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper.shipping name,and areclassified,packaged, <br /> marked and Iabeledfplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expod shipment and am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. - - - <br /> I certify that the waste minimization statement identified in 40 CFR 21(if I am a large quanttty generator)or(b)IN I am a small quantity generator)is true. <br /> Signature Month Day Year <br /> Generators�Offerors PdntedlTyped Name - Si g C 7 _ k <br /> .International Shipments <br /> El Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> ZDate leaving U.S.! <br /> Transporter signature(for exports only): <br /> Ce 17.TransporterAcknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 PrintadlTy ame Signatu Month Day Year <br /> Z Transpo or rintedlTyped Name Signature Month Day Year <br /> r <br /> 8:Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Foil Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPAID Number <br /> J <br /> U <br /> tQi Facil!snaPehone.oMonth Day Year <br /> ILLI <br /> 1 V Sigturf Alternate Facility(or Generator) <br /> Q <br /> Z <br /> C9 19.HazaMous Waste Re d Managerntent.Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1 2. 3. 4. <br /> G <br /> 20.Designated Facili e r tor:Certificati n of recei hazardous materials covered by the manifest except as noted ttia M �LWOPY <br /> Printed/Typed NameSignatureEPA Form 8700-22((Rev.12- revious editio ar tDESIGNATE F <br /> f 1 761( �($� I I THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE. <br /> Page 17 <br />