Laserfiche WebLink
SSL SK SHIP# , 29555338' <br /> Please print or type. !�—7�� � ✓� 0 1 Form Approved, MB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL000392820 .P i o 3. m R 4.Manst Tracking Number <br /> - '- ` i0 th007180586 SKS <br /> WASTE MANIFEST a71�17 <br /> 5.Generator's Name and Mailing Address Generatoes Sire Address(if different than mailing address) <br /> O'Reilly # 3020 <br /> 309 W Dr Martin Luther Ki <br /> STOCKTON CA 95206-1705 <br /> Generator's Phone: 972-555-1459 <br /> 6.TrfeWorgpanv3Jam�e SYSTEMS INC U.S.EPA ID Number TX R@00081205 <br /> 7.Transporter 2 CComtppaLnyy Ntaim4e U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> Facility's Phone: SAN JOSE , CA 95133 <br /> 408-441-0962 CAD059494310 <br /> 9a. 91c.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wit./Vol. <br /> 1 NON—RCRA HAZARDOUS WASTZ,, SOLID, 1 DM I P 181 <br /> o ABSbRBENT AND OIL), (� <br /> L <br /> W <br /> 2 <br /> W <br /> 3. <br /> 4. <br /> 14.SpedafHandling Instructions and Additional Information TSD:SJ 81160739 QniAby <br /> OR14472q�jCS624H EMERGENCY#800--468-1760—CH/SK/TFI—Contract reftgr l aggency authori y <br /> on initial trans orter to add ar substitute addiai trans artery an enerator's behalf. <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately desaibed a ve by the roper 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 _men Mations.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 Co nt <br /> I certify that me waste mini 'zation statement identified in 40 CFR 262.27(a)(if I am a large quan8ty generator)or dl a qu nerator)is true. <br /> Generator rs Pd ad <br /> ,Alame Sign re Month Day Year <br /> 16.lntemati al 5hpirellbel <br /> F— ❑Import to 115. ❑Export from Port of entry At: <br /> i Transporter signature(for exports only): Data leavi U.S.: <br /> IX W 17.Transporter Acknowledgmentof Receipt of Materials <br /> I— Trans o r 1 PrintedlT Name <br /> Signature C re Month Day Year <br /> CL Cl X-, <br /> Z Transpo r 2 Pn ed y me Signature h Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 1 ❑Full Rejection <br /> Quantity ❑Type ❑Residue ❑Partial Ra ectien <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> � U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> r18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2. <br /> 20,Designated Facility 4ner or Operator:CeNfication of receipt of azardous materials wyerjd by the manifest except ned in Item <br /> PdntedRyped Name Signature Month Y <br /> EPA Form 870-22 Rev.12-17))Previous editions a solete. DES7�TY 70 EPA's e-MANIFEST SYSTEM1)7361257/ ob40559605 IG <br /> OR 14472_WT_007180586SKS 14 <br />