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SK SHIP# 232526727 Illiiillllil�Il�llli�l�i IIII���Ili <br /> 007769730SI< S <br /> Please print or type. Form Approved,OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.GertetalorlD NtxrtberirALIA 4r-.,- 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST j i 007769780 SKS <br /> 5 3cmeratc s Name and Mailing Address Generators Site Address(if different than maiiing address) <br /> -ay Mach r4 L.Ic <br /> S Pershing Ave <br /> .S, O&KTON CA 95206-1177 <br /> Generators Phone: 2-09- 4154--91 <br /> Tr U.S EPA ID Number _ <br /> a"sp�w�ilt -- n " SYSTEMS INC Tk€��',@00$1 2�'" <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> ! SVC INC. MAD039322250 <br /> i <br /> 8 Designated Facility Name and Site Address CLEANHARBOISS OF BUTTONW I L L OW U.S.EPA ID Number <br /> 2500 LL3KERN ROAD <br /> I BLITTONWILL_OW , CA 93206 <br /> x-:61-762--9200 CAD960675276 <br /> Facility's Phone, <br /> 9a 9b.U,S DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HMP king Group(If any)} No T,oe Quantity Wt,"Val. 13.Waste Cocks <br /> 1 ON RCRA HAZARD[} 4 WASTE SOLIDS 552 <br /> 0 (OIL, DIRT AND SAND), N ID — <br /> a <br /> w <br /> w <br /> 4- <br /> 14.Special Handling Instntctions and Additional Information TSD:6L 8426163 u c:tet <br /> Li <br /> ,T=-`—Contract r ewained by generator confers a5ency authnr <br /> ;tial trans ci -stitute additional trans orters on enerator' s behal <br /> 15. GENERATOR'SIOFFEROR'5 CER71FICATI0Nv 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 Iabeledlplacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(I I am a small quI generator)is true. <br /> Generator' 'Offeror's Printed/Typed Name Signature Month Day Year <br /> btT - 11011 <br /> J.16.1n1 motional Shipments <br /> i" ❑Import to V S Export from U.S Port of entrylexit: �- <br /> ? Transporter signature(for exports only)', Date leaving U,S.: <br /> 1 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> T nsporter 1 P inted T amu ure Month Day Year <br /> IXZ 120 <br /> z Transporter 15FnIe&7yued Nare lure Worith Day Year <br /> a <br /> zo <br /> 18.Discrepancy <br /> 18a-Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Fatuity's Phone: <br /> W 18c,Signature of Aitemate Facility(or Generator) Month Day Year <br /> f— <br /> Q <br /> z <br /> N19-Hazardous Waste Report Management Method Codes(i-e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 t 2, 3. 4. <br /> 13z- <br /> 20.Designated Facility Owner or Operator:Certkf�cation of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed Typed Name Signature Month Day Year <br /> Ch V d P.1 ZD <br /> EPA Form 8700-22 iRev 12-17) P-ev ous editions/e obsolete. DESIGNATED FACILITY/O EPA's e-MANIFEST SYSTEM <br />