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SK SHIP# 23194200° Illilllllllllllllllllllllllllllllllll <br /> 0 0 7 3 1 3 6 5 6 S K S <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page.1 of 3. m R s e PMA <br /> 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS �,!?I_t�t71i21tA147F�? 1 ��"�'��1f�� <br /> 1007313656WASTE MANIFEST SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Calaveras Materials Inc. <br /> 1945 Lathrop Rd <br /> LATHROP CA 95330--0000 <br /> Generator's Phone: 559-469-3838 <br /> s.Tr§W Corr r,� SYSTEMS INC U.S.EPA ID Number TX R000081205 <br /> 7.Transporter I2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC, iMAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BllTTONW I L.LOW , CA 9320E <br /> 661-762-6200 CAD 9817+670.76 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and V-1 <br /> g Group(if any)) No. Type Quantity Wt.Nol, <br /> 1 NON RCRA HAZARDOUS WASTE SOLIDS, ISM jOr1 P cam` <br /> o iGREhSEI, 0illillIll ! <br /> Z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:BL 83775829 CA67265 <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers afpency authori <br /> on initial transporter to add or substitute additional transporters on qeneraorls behalf. <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 labeledlplacarded,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 /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if lam a small quantity generator)is true. <br /> Generator'sjpfferor's Printed/Typed Na Signature Month Day Year <br /> /411-f ; �4 7 1 Iq 10-v) <br /> 1t.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> I-- Tra iter i PrintedfT ed Name Signa r Month Day Year <br /> C ' "PE 7 <br /> a <br /> Z Tr sporter 2 Printed/Typed Name Signature Month Day Year <br /> 9 <br /> G.�t ► u�,�� G 1Z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> U) 19.Hazardou Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. 2. 3. 4. <br /> 20.Design/ cility Owner or Operator:Certificatio f receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printe Nam r� " Signature Month <br /> EPA , 8 072�fR 1 P-fious editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> Page 19 <br />