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SSL SK SHIP# 234419620 <br /> Qd7 # � � 4 �•1R.sl�����. s <br /> Please print or Type. Form Approved.OMB Na.2056 E}039 <br /> RM HAZARDOUS 1.Generator IU Number 2-Peg t of 3!=m nee 4.IM�iFea'flNumber <br /> r�WASTEMANWEST CAL000392598 -- � �+�it3 O 5923. <br /> A G 3. SKS } <br /> robes Now jn�Y i ress —._ Generator's Site Address{VdKerent than malling address) a <br /> etJb <br /> 3323 N Tracy Blvd <br /> TRACY CA 95376:--1720 <br /> Generators Phone: 209-8316-0606 <br /> s.T� _ SYSTEMS INC V.S.t�41D Number TXROOOO81205 s <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> i--LEAN HkR]DIuRS ENV SVC INC. MAD039322250 <br /> 8 0esigreted Facility Name and S ke AddressCLEAN HARBORS ARAGONITE, LLC us.EPA DNumber � <br /> 11600 NORTH APTUS ROAD <br /> ARASONITE UT 84029 <br /> 435.884-8100 UTD981552177 { <br /> FacilWs Phone, <br /> ga. 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Urtit 13.yyste Codes <br /> HM and PaCkIN Group(ti any)) No. Type Quantity WLVCL C �y <br /> 'I. �t, r,,-- -...r�- r: :moi:�.,; 5��: r• _ } DM � F00 i F002 F003 <br /> Q p, y r �$ s'rti _ 5 rI ■■■ <br /> F005 D0$1 135 <br /> x <br /> 3 <br /> 4, <br /> `l . <br /> T4.Special Harm In&uctions and Addi arW Infamration TSD:AG 86365865 OR 14422 CSG: <br /> f$ERQ#128l 10 L.�7 ->a-1 V7 <br /> 24H EMER86•�NCY#800w-458-1760—CHIS /TFI--Contract re wined by generator confers agency authority <br /> can initial trans orter to add or substitute addi 'ono tr ns carters. n ra� r' behalf. <br /> I& GENERAMOR'W0FFER0WS t6RnFICA7MN:I hereby dedare that the contents of tints consignment a accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and lateledlplacarded,and are in all respects Wi proper condition for transport according to app i lb"and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I cer*that the contents of this consignment conform to the tears of the altadted EPA t rraerrt <br /> I oerttiyy That itte waste minkrdzation statement identified in 40 CFR 262.2T(a)(ifI am a large quantity rotor) (b) 'lama nttiy generator}is true. <br /> s thi ala re Month Day Year <br /> � 7 <br /> F sfional Shipments Import to U.S. <br /> ❑Export from U.S. Port of exit: <br /> = Transporter signature{for exports. Data leavng <br /> W 1T.TmnsparterAdutowkigmentof Rbc*of Materiehi <br /> 4 <br /> TnEgEder 1 Printedf( Name Sign Adomh Day Year <br /> Tran Y 2 Prifitaciffyped Name Sign Month Day Year <br /> O 5 <br /> 18.Dscreparr y <br /> 18a.Discrepancy Indication Space ❑ ouanOity ❑Type ❑Residue ❑Par&Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> C? <br /> Fadlltyrs Plane: <br /> W 18c.Sig"ft of A Wriate Facility(or ero ra r) Month Day Yep[ <br /> 18.HKardbus Wage Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycfng systems) <br /> - 1.;... 3. 4. <br /> 20,Desgnated Facirdy owl or OpqW.Certification of receipt of hazardous materiaE covered by the rnmr bstsxoept as nod in Item 18a <br /> NameMonth 0 y� <br /> EP�f" �reviatts are obsolete. DESIGNATED FACILITY TO EPA'S t MA !FEST$YSTE <br />