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SSL ,SHIP# ,.229350753 <br /> Please print or type. 4 t, ' 'w.J Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Eme enc Respon a Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST . CAL000393232 I_aa-4,g�175100715930TSKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing afldress} <br /> O'Re i l l y.. .#I: 3460 - '��- <br /> t 1210 N Tracy Blvd } <br /> ` TRACY CA 95376--3435 <br /> Generators Phone: <br /> 972-555--1554 <br /> 6.Tr§hV9f q P E&% STEMS INC U.S.EPA ID Number <br /> Ft l if"fSf.. ,�f T X R9300081205 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD639322250 <br /> B.Designated Facility Name and Site Address. CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA tD Number <br /> 2247 S HIGHWAY 71 <br /> K I MlB�ILL , NE 59145 WD981723513 E <br /> 308--235-4012 <br /> Fadlitys Phone: <br /> 9a: 9b.U.S.DOT Description(including Proper Shipping,Name,Hazard Class,fD Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Ouantity Wt./Val. <br /> o X 1. NA3082, HAZARDOUS WASTE, LIQUID DM P D 1101 �� <br /> 0 N.0.S., (BENZENE, LEAD), 9, PG II <br /> ILI f� <br /> Z 2. <br /> ua <br /> c� <br /> 3. <br /> 4. <br /> 14,,SpecalHandlingInstructions and Additional lnformation TSD:KP 80ga7617 DR14348 CSG. <br /> 1 F_RG#i1711 tgj <br /> 24H EMERGENCY#1;800-468-1760—CH/SK/TFI—Contract retained by gen rator confers aon initial transporter to add or suhSt - uthori y <br /> if- <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: t hereby declare that the contents of this consignment are fully and accurately described a-blve by the proper shipping name,and are classified,packaged, <br /> marked and fabeledlplacarded,and ere in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary:' <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgmen$ onsent awr, <br /> l certify that the waste minimization statement identified in 40 CFR 262,27(a) €f I am a large quantity gerigglW)tif I am a small quantity generator)is true. <br /> OfferorsP'nted/TypelName na Month Day Year <br /> 16.Intemafi al Shipments <br /> P- ❑Import to U.S. ❑Export from Port of entry/exit: 1 <br /> l <br /> ? Transporter signature(for exports only): Date leaving U.S.: � <br /> ix W 17.Transporter Acknowledgment of Receipt of Materials <br /> jj <br /> or 1 Printed)Typed ' nature Month Da :Year <br /> / y <br /> �► 3 r <br /> Z er 2 Print ame i4 i Me Ory Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑buantity ❑Type ❑Residue ❑P*.I Rejection <br /> ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> LLj 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z F i <br /> r <br /> rn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. qo 2. - 3. 4, <br /> 20.Designated Facility Owner or.Operator:Certification of recef" hazardous materials covered by the manifest except as nuted in Item 18a <br /> Snature r <br /> Printedrryped Name ' qr pth Day Year <br /> ca <br /> EPAForm <br /> 74S7p0 2(R�vBry12-17]_P7revious editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 3 k�t 5� � <br /> A <br /> r <br />