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SSL SK SHIP '- =-*W3-=x0 23`5u007768941 SK1 Please print or type. Form Approved.OMB No 2050-0039 UNIFORM HAZARDOUS 1.Generator I7 Number , 2.7ageJol3. m R s e P 4.Manifest Trackin Number CAL000E 9323c = � 0077 6 8941 SKSWASTE MANIFEST 5.Generator's Name and MailiAddress Generator's Site Address(if different than mailing address) O'Reilly # 1460 1210 N Tracy Blvd TRACY CA 95376-3435 Generator's Phone: 972-555-1554 1 6.Trat�poriazrl.CompanySJame SYSTEMS INC U.S.EPA ID Number TX R$00081205 7.Traarpto'rtterf2 CComtSaLny�Nea lmde �.EPA ID Number CLEAN HRBCRS ENV SVC INC. —� iMAD03932":250 8.Designated Facility Name a nd Site Address CLEAN HARBORS ARAGONITE, LLC U.f.EPA ID Number 11600 NORTH APTUS ROAD ARAGONITE , UT 84029 43C'-884-8100 L UTD98155*2177 Facility's Phone: _ ga 9b.U.S.DOT Description(including P oper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.IV01. X 1. NA3082, HAZARDOUS WASTE, LIQUID 1 DIM 3DU P D00 D018 331 o N.0.S., (BENZENE, LEAD), 9, PG ri I I - � z _ — w 3. 4. 14.Special Handling Instructions and Additioral Information TSD:A13 8490/127 OR14348 CSG: n i)ERG#171° �:� �� 24H EMERG�N(:Y#800–At68-1760–CHISKITFI–Contract retained by genera or confers agency al.ithori y on initial transporter to add or substitute additional transporters on generator's b?half. 15. GENERATOR'SIOFFEItOR'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,pa;kaged, marked and Iabeledlpla,:arded,and are in all respects in proper condition for transport according to applicable international and national governme ital regulations.If export shipment and I am the Pr mary Exporter.I certify that tha contents of this;consignment conform to the terns of the attached EPAAckncwledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity ger erator)or(b)(if I am a small quantity generator)is true. rGenerator's/Offeror's PrintedlTyped Name Sicnature Month D;ay Year International Shipments I— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for ex)orts only): _ Date leaving U.S. W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 PrintedlT ed t me Signature �— Month Day Year IL Z Transporter a yped Name gnatur Month Day Year t l 18.Discrepancy ILi 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Partial Rejection El Full Rejection _ Manifest Reference Number: _ 18b.Alternate Facility(or Generator) U.3.EPA ID Number J � Facility's Phone: _L Lo 18c.Signature of Alternate Facility(or Generetor) Month Day Year Q Z -- N19.Hazardous Waste Reporl Management Mathod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) _— G 1. 2. 3 4. 2b.Designated Facility Owner or tor:C artification of receipt f hazardous materials covered by the mE,nifest except as noted in Item 18a Printed/Typed NameL�' / Signature Month Day Year 1 �—' I [a- I a 00 EPMA99YO-6,11�4Z efevious elitions are obsolelle. DESIGNATED F{,CILITY TO EPA's e-MANIFEST SYSTEM