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SSL SIC SHIP# 231794147 f)Iease print or type. 0 0 7 4 4 0 2 S 9 S K S — Form Approved.OMB No.2050.003 3 1.Generator ID Number 12.Pat1NIF�RM HAZAR00U5ge 1 of 3.Eme n Res o e p e 4.Manifest TsacktWASTE MANIFEST CAL031 1~ ~~ ! , 1007440289 V 5.Generators Name and Malting Address Generators Site Address(if different than mailing address) 1� O'Reilly 2736 TRACY N racy Blvd CA 95376--1720 Generators Phone: 209-836-06 112116 6.Tran rter C�gm any Name S E� 12V STEM INC U.S.EPA ID Number TXROOMIM 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENV SVC INC. 93222 a,Designated Facility Name and Site Address CLEIAN HARBORS ARAGMITE, ILC U.S.EPA ID Number 116M NORTH APTUS ROAD AitA IITE , SIT 84029 h35--884-81 UTD%15WI77 ` Facility's Phone: r} 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11•Total 12.Unit HM and Packing Group(if any)) No. Type t]uantlly WCNot. 13.Mate,Codes X 1' 2, ZARDf11J5 QST);, LIf10 DM PiB 331 .0.S., (BENIN, LEAD), 9, PIG ' II 3. 4. 74.SpedA Handling Instructions and Additional Information TS &36BM7 Ni 4 , ; y 1)ERB*171" 24(1 'E1 # -4G&-1760-CHf ilTF'I-Contract retained by gen ;Moor conf � e �y authari y t5. GENERATOR'SIOFFEROR'S CER tWq` A71ON:I hereby declare that Ste contents of this consignment are fully and accura",desr�bed above by the proper shipp are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If a shiprltent and I am the Primary Exporter,I certify that the contents of this '' merit conlbrm to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization sta ,r nt:ideetified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(91 am a small quantity generator)i true. GeneratceslOfferors Printedrryped Name Si ` Month Day Year r 16.International Shipments F import to U.S. ❑Export from U.S. Porto enhylexit:' E Transporter signature(for exports only); Date leaving U.S.: 17.Transpo erAdmowledgment of Receipt of Materials i5 Transporter 1 'to ped Name Signature Month Day Year Lo I Trans d yped Name f Sig ratiHe Month Day Year 18.Discrepancy 18ar Discrepancy indication Space ❑ Quantity ❑TYPe ❑ id. ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18h.Alternate Facility(or Generator) • U.S.EPA ID Number y V ri 1-adhty's Phone: _ ,t Fyj '8c.Signature of Ahemate Facility(or Generator) Month Day Year Z �n 19.Hazardous Waste Report Management Method Codes(i.e.,codes.for hazardous waste treatment,disposal,and recycling systems) iLI 12" g U 4. 20.Designated Facility Owner or Operator:Certification of re ipt of hazardous materials covered by the manifest except as ride in I m 18a Frintedffyped Name Signature Month Day Year Ll O o EPF. 87Rev.12-17 Previous editions are obs fete. ].) DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM 74933433 �/8295�7 ;