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- SIS SHIP# 231942075 II I II I I II S I I U�nl l llll l l n l <br /> Vaoo800�- 7 5 7 S K 3 <br /> Please print or Type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number CALOOOO 14763 2.P 1 of 1 3.Eme�Rgsppgse ihpnE, Manifest Tracking NumbeWASTE MANIFEST <br /> 14 . <br /> 007313657 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Calaveras Materials Inc. <br /> 19-45 Lathrop Rd <br /> LATHROP CA 95330-0000 <br /> Generator's Phone: <br /> 6.Tr9ff�YY ftr.VtR SYSTEMS INC U.S EPA IQ Number T XR000kd81205 <br /> 1.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENY SVC INC. MAD039322250 <br /> 8 Designated Fac;lity Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA IQ Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL , NE 69145 <br /> NED981723513 <br /> 308-`35-401 <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 Packing Group(if any)) No Type Quantity M.Nol. <br /> X t UN1268, WASTE PETROLEUM DISTILLATES, DM ' da F DOl 2'1�. <br /> 0 N.O.S. , :i, Ill III <br /> w <br /> Z 2. <br /> LU <br /> C� <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Informationa <br /> TSD:I;F 83775829 Ci-tis <br /> i)ER5#13-'8; <br /> 24H EMERGENCY#800-468--1760-CH/SK/TFI-Contract retained by generator confersaqency authori y <br /> an initial transporter to add or substitute additional transporters on enerator' s 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,anid 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 t 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 I am a small quantity generator)is true. <br /> Generators( erors P,intedfTyped Na 5igriatu Month Day Year <br /> `T Iq I ao <br /> 16.International Shipments <br /> F ❑Import to U.5. Export from U.S. Port of entrylexlt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> tY 17.Transporter Acknowledgment of Receipt of Materials <br /> Ow~C Tgporter 1 PratedWyNa Signa l 3 Month Day Year <br /> CL <br /> Z Transpo rintedlTyped Name Signature _ Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Duantity, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> I8,Alternate Facifity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ti Fadlity's Phone: <br /> w 18c,Signature of Alternate facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19,Hazar ous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> C 1 2 3. 4. <br /> /&V <br /> 2 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest expaq as noted in Item 18a <br /> PrinledfTyped NameSignatur _ Month Day Year <br /> I &— �J - - I - I191 / JX <br /> EPA Fo g�j7QQD-zRe G 102-r71 tvious editions are obsolete. DSI E FACILITY TO EPA's a-MANIFEST SYSTEM <br /> Page 20 <br />