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SSL <br /> /print or type. SK SHIG# 'L2g21r590 nl�llul�'I �III��It�I�� <br /> �PI� 0 0 7 9 1`80rm Ap1 p Sproved.611 Wo.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Erne n RQs Dose T 4.Manifest Tmcking Number <br /> WASTE MANIFEST CAR000039370 1-819eN. 4�$-1 ll� O� �© �+�/� <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) O SKS <br /> Escalon Premier Francis Inc. <br /> 1905 Mchenry Ave <br /> ESCALON CA 95300-0000 <br /> Generators Phone: 209-552-6051 <br /> 6.Tr�5pFry' rrlp;nftT SYSTEMS INC U.S.EPA ID Number <br /> HHtt tt KKL�.�N TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 <br /> Faalitys Phone KNOLLS UT 84083 <br /> 435-884-8915 ' lJTD991301748 <br /> ga 9b.U.S.DOT Description(including Proper Shipping NameHazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.fvoL 13.Waste <br /> , Codes <br /> 1 'td Ib' ON RCRA HAZARDOUS WASTE SOLIDS, DM G 181 <br /> 0 (NON GCB BALLAST), .y¢A �O <br /> up 2. <br /> w <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TSD GM $0I749537 ES12014 <br /> CSG: <br /> 24H EMERGENCY#800-46$-1760-CH/SK/TFI-Contract retained by generator confers a en�y arathori y <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Thereby declare that the contents of mus consignment are Polly and acourAlf- <br /> ately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ff I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generators/Offero nnted7ryped Name _ Signature Month Day Vear <br /> r ^I Q <br /> 16.International Shi ants ❑Import to U.S. ❑Export from U.S. ono entryexit: 63 P1! I <br /> H <br /> i Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T Jeri P'nted7Typed me Month Day Year <br /> �*. VG R1� 8 Ig <br /> = T 2 Print dRypad Name Signatu opih Day Y�ar <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quaintly ❑TYPe ❑Residue ❑Panial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 180.Alternate Facility(or(3enerator) U.S.EPA ID Number j <br /> U <br /> LL Faalitys Phone: ! <br /> w 18c.Signature ofAltemate Faality(or Generator) <br /> 4Month Day Year <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1. 2. 3. <br /> 4. <br /> 1 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ni in Item 18a <br /> PnntedRyped{Jame y�' <br /> } Signature Month Day Year <br /> EPA Form 0135-22(Re .12-17) Previous ditions are obsolete. ESIG D FACILITY 's e-MANIFE T SY TEM <br /> 138£820501 $79`c'94 TO EPA <br />