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(&PSL8K 5HIP# 234544663 WL Form Approved.OMB No,2050-OM <br /> UNIFORM HAZARDOUS 1.Generator ID Number T k 8000081205 2,Pan 1 of 31Fmggdppy <br /> WASTE MANIFEST 1 rOkF Re�onsePpppe� 0078 <br /> O 7 8 5579 SKS <br /> 4bFi 1 f <br /> 5.Generator's Name and Marling Address Generator's Site Address(if different Nen mailing address) <br /> ��FI�TY—fiE_EEi� SYSTEMS, INC. SAFE Y--KLEEN SYSTEMS, INC. <br /> PO BOX 5555 5050 SAL I DA BUND <br /> SNL I DA CA 95369 <br /> GeneralorsPhone: 20'9-545-1011 SF1L.IL}k GH 95356 <br /> e�IM SYSTEMS INC U.S.EPA IO Number T k 80003081 X05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> GLESIIN F#AkBORS ENV 54C lNiL. MATiI2113932E2510 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNUL.l_.a EXIT 41, OFF 1 -80 <br /> KNOLLS , UT 84083 <br /> 4.35. 884-8915 UTD9913017746 <br /> F Phone: <br /> 989b.U.S.OOT Description(including Proper Shippvq Name,Hazard Class.10 Number. 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Paddng Croup(d anyl) No. Type Quantity H4.No[. <br /> F 1. N€)N—RCRA HAIAR13015 WASTE 5€71_ILS OM P 223 <br /> (DRAINED AND UNDRAINED OIL FILTERS) <br /> €5SED TOIL FILTERS CONTAINING USED OIL <br /> W 2 <br /> t9 <br /> 3. <br /> 7 <br /> 4. <br /> 14.Special Herding Irtstnhctions and Additional Inkmrabon TSD:GCS SPL CSG. <br /> 'AH EMERGFNCV#800-468--176€0-CNiSK/TFI-Contract retained by generator confers agency authority <br /> on initial transporter to add or substitute additional transporters on Ill tar' s behalf, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare Net One contents of this 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 to proper conciltlon for transport according to appllcable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify Nat the contents of this consignment conform to the terms of the attached EPAAcknowk*ment of Consent. <br /> f cw%[hat the waste minimization statement identified in 40 CFR 262.27(a)(if t am a large quantity generator)or(b)(if I am a small quantity gereratoo is true. <br /> si P' Name Mon lay yew <br /> IP slve, <br /> x" I <br /> ❑Import to U.S- ❑Evart tram .S. Port of entrylehdt: __.. <br /> al Z-:rlorlsl(for exports onty): Elate leaving U.S.. <br /> W 17.Transporter Acknowledgment of Recelpl of Matsnals <br /> T r 1 P,wrryped me S Mvnth Day Year <br /> 17. Z <br /> Tran PdrdedlTyped Name Slg re r Month Day Yaer <br /> ' .2 P0 <br /> 18.Disorepanuy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altamate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facility's Phone- <br /> W ]8c.Signature of Niemate Facility(or mr) Mach Day Year <br /> a <br /> Z <br /> 9 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatrnent dispose[,and recycling systems) ; <br /> c 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a L� <br /> Nntedrryped Name nature ] <br /> Month Day ear <br /> 41-L !! l� zr <br /> EPtf f2&6�1�1 �- Previous " s are obs*te. OE5IGNATED ACILI TO ERA's e-MANIFEST SYSTEM <br />