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SSL. SK SIS I P4# 23558"13r V— (� � <br /> Please print or type. 9 Q Form Approved Okl No YU50d1039 <br /> UNIFORM HAZARDOUS 1.Generator 0 Number CAL000393245 2,Page 1 of 3.t=Sc rjnsg p}7 14lJlan�Fe�Tir�g 9 5 <br /> WASTE MANIFEST 1 1 4b J-1! 0 1 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> O%Reilly # 3477 <br /> 420 W Lodi Ave <br /> LOD I CA 95240-3423 <br /> GerheratarsPhone: ���-369—�`��� i r <br /> s.9?ffY219�VSYSTEIMS INC U.S.EPA ID Number TXR00008 205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. IMAD039KE22510 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAID! JOSE , CA 951.33 <br /> 408--441-0%2 CAD0594-�43 z0 <br /> FOCI'es.Phone: <br /> ga. 96.U.S-DOT Description(including Proper Shipping Name,Hazard CAass,ID Number, 10-Containers 11.Total 12-Unit <br /> and Packing Group(if any)) 13-Waste Codes <br /> HM No. Type quantity Wt.Nc!- <br /> (M ThLNDUSTLRA AND MACHINIOUS NG N 31VEsWAWA51 L 12),,E SOLID, P 172 <br /> W <br /> 2, <br /> W <br /> 0 <br /> 3. <br /> k <br /> 4. <br /> 14.Spedal Handling Instructions and Additional Information <br /> TSD.-SJ 88361434 CR 1`,X35 CSG-. <br /> SS' r <br /> 24H EMERC ICY#800-468-1760—CH/SK/TFI—Contract retained <br /> by generator confers agency authf3rit <br /> l I I <br /> on initial transporter to add or, substitute additi nal 1-rans artery angenerator's behalf. <br /> 15- GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this Consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and laheledlplacarded,and are in all respects in proper Condition for transport according to applicable international and national <br /> governmental regulations-If export shipment and k am the Primary <br /> Exporter,I certify that the contents of this consignment oonform to the terms of the attached EPA Acknowtedgment.of Consent- <br /> I cel*that the waste minimization statement identified in 40 CFR 282.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Genherators70 mss Pnniedffyped Name Signature Month Ety Year h <br /> VE p_0 ti[L.pr LCL..p IN 123 <br /> 16.International Shipments <br /> F ❑Importto U.S. ❑Exportfrom U.S. Part of entylexib <br /> Z Transparfer signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T er 1 PrirdadlT Name Signatu Month DO Year <br /> O <br /> a 7J <br /> Transpo 2 ype me SO)ature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residueejecwn ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V 4 . <br /> LL Fadlity's Phone: <br /> W 18c.Signature CfAltemate Factiity(or Generator) <br /> Month Day Year <br /> a <br /> x <br /> co 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recydnhg systems) <br /> LU 1 2. <br /> 3. 4, <br /> 20,Designated Facility Owner or Operator Certification of receipt of(hazardous materials Covered by the manifest ex*t as noted in Item 18a <br /> Prin y Nae Signature ,ort A Ye <br /> EPA <br /> F9o�87 0-22/6ev41��2ii )1Previous editions are obsolete. D:SIGNATED FACILITY A'S B=MANIFEST SYSTEM <br />