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aI_ SK SHIP# 235954658 <br /> 007762603 � K.s <br /> Please print or type. Farm Approved.flMl3 No.2fl5D QQ3g <br /> UNIFORM HAIAWUS 1,Generator ID Number � � 2.Page 1 of 1 Erpeyygpcy4�sppra P.mb 4,Manifest TradiNbar <br /> WASTE MANIFEST tSnia ❑ii 1 r[> 00779,2"60,3 SKS <br /> 5-Generator's Name and Mailing Address f Generaloes She Address[if Offerent than mailing address] <br /> O'Reilly # 27,36 <br /> 3323 N Tracy Blvd <br /> TRACY CA 95.376-17210. <br /> Generator's Phone: 209-836-0606 <br /> s'��ffW SYSTEMS INC U.S.EPA ID Number TX 8000081205 <br /> 7.Trans iter 2 Compan Name U.S.EPA ID Number <br /> C AhI !IAR ORS ENV SVC INC, MAD 039322250 <br /> 8.Designated Fadllty Name and Site Address CLEAN HARBORS GRASSY M€UNTA I N U-S.EPA ID Number <br /> 3 .MILES EXIST, 7 MILES NORTH KNOLLS EXIT 41. TIFF I-80 <br /> ; 1�f3LLS = LIT Q4083 <br /> 435-864-8911..,:,.14UTD991301748 <br /> FaclliPhone: <br /> ga. 9b-U-S-DOT Description(ncluding Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pa6drg Group(9 any)] No. Type Quantity WuVol. 13.Waste Codes <br /> t rte- NON-RCRA HAZARDOUS WASTE SOLID � DF �� P 172 <br /> Cf. t M-EThL DUST AND MACHINING WA51� 172), ' <br /> 110 IAOL=- NON-RCRA HAZARDOUS WASTE, SOLID, DM r �� P 181 <br /> c� 5-BH lRli FENT AND OIL), NA4 � [ <br /> 3. <br /> 4. <br /> 14.5peaal Handling lnstrue*m and AddfUonal Information TSD:SM 87922977 ' <br /> OR"14422 CSG-. <br /> 24H EI4ERGENCY#800-468-1760-CH/SK/TFi--Contract retained by generator confers Ngericy author�it <br /> r•at <br /> an initial transporter to add or substitute additional transporters on eneor''s behalf. <br /> 15. .GENERATORWOFFEROR'S CERTIFICATIOW I hereby declare fiat the oordents of tNs consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> :.:.marked and iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter.;certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br /> I cert fy.lhat the waste m nimization statement identified in 40 CFR 26227(a](rf I am a large quant ty generator)or(b](rf am a small quantity generator}is true. <br /> G is Printed/Typed Name Signatu Month Day Year <br /> 16.Inkff0onal Shipments ic <br /> F-- ❑Import to U-S. ❑Export from U.S. Port of entryfex t: <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> W 17-TransporterAckr wleegment of Receipt of Materials <br /> aT ce 1 Priny arae Signatu Month Day Year <br /> IM J- 172 <br /> aTrensporle 2 P mclflyped Name Signature • Month Day Y <br /> 18.Discrepancy <br /> iso.Discrepancy Indicatim Space <br /> Quantity Type Residue Partial Rejection El Full Rejeo]ion <br /> Mandest Reference Number: <br /> 18b-Alternate Facility(or Generator) U.S.EPA 0 Number <br /> U <br /> LL Facility's Phone: Year <br /> w 18c.Signature of Alternate Facility(or Generator] Month Day <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Coes(Le..codes for hazardous waste treatment,disposal,and recyding systems) <br /> LU 1. 2, 3. 4. <br /> Zo.Designated FacMity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as rioted in Clem 1B .d> <br /> PrirdedlTyped Name Signature Mo1rfh: <br /> Edi E DESIGNATED FACILITY TO EPA's�.M►��F <br />