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SSL SK SHIP#.ai*PWiti., �AIIIII �� � I�nI ��I ��I <br /> Please print or type. �?/7 0 (0 9 0 0 0 R 9 5 9 6 2 3 S K s <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Enver en Res nae Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000393232 1 1-8�0 -4 8-1760- ..1006959823 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> D'Rtzilly # 3460 <br /> 1210 N Tracy Blvd <br /> TRACY CA 95376-3435 <br /> Generators Phone, 972-555-1554 <br /> 6.Trans arter 1 Com any Name U.S.EPA ID Number <br /> SfNFETY-�CLEEN SYSTEMS INC TXROOOOB1205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Fatuity Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA 10 Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> CAD059494310 <br /> 408-441-0962 <br /> Facility's Phone: <br /> 9a. 9b.L.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and P ing Group(if any)) No. Tye pQuantity Wt.Ndl, 13.Waste Codes <br /> 0 1. 1" NON-RCRA HAZARDOUSIPSTE, SOLID, / DM �� P 181 <br /> F (ABSbRBENT AND OIL), ifjr I <br /> W <br /> IM 2, <br /> W <br /> CD <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:S J 79321964 OR 14348 CSCS• <br /> l � 1"I-a 3, u a U <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers a enc, allt"ori, <br /> y <br /> Pr <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 labeledlplaearded,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)(ifl am a small quantity generator)is true. <br /> Ge eratOfrerci PurtediF _d Name Signature�}� 9 z�. Month Day Year <br /> MA 0 <br /> J 16.Internationai Shipments \J 3 <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> Tran ner 1 PrintedfTyped Name Signature I M Day Ye <br /> a <br /> rn <br /> ed Name Si ure <br /> a � Month Day, 7Yea <br /> 1B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type <br /> ❑Residua El Partial Rejectlon L1 Full Rejection <br /> } 18h.Alternate Fami Merriest Reference Number <br /> F ty(or Generator) U.S_EPA ID Number <br /> J <br /> U <br /> u- Facility's Phone. _ <br /> w 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e-,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1. 2. 3. 4. <br /> Ll20.Designated Facility 0 r Operator Certi cation of tot hazardous materials covered by the 1 inake./ Imanifest except ..it em 18a <br /> PrintedlTyped Name r, Signature a <br /> EPA Form 8700-22(Rev. revioue ition re obsolete. DESIGNATED FACILITY 70 EPA's e-MANIFEST SYSTEM <br /> 1)7361257/405 9605 <br />