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SSL SK SHIP# 'i?30597414 <br /> Please print or type. <br /> 1.Generator ID Number ' Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2. ge o 3. e�g0�y R me Ppp�, 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL00039324$ +" — -1 tae 1007275713 SKS <br /> 5.Generator's Name and Mailing Address Gerarator's Site Address if different than mailing address <br /> O' Reilly # 3477 ( s ) <br /> 420 W Lodi Ave <br /> LODI CA 95240-3423 <br /> Generators PhoneD: 209-369-1988 <br /> 6.Tragypgpp01GOmpaPylJyO/e SYSTM INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.uEPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8..Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> 408-441-0962 SAN JOSE , CA 95133 <br /> Facigty's Phone: CAD059494310 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Claw.10 Number, 10.Containers 11.Total 12.Unil <br /> HM and Packing Group(if any) 13.Waste Codes ' <br /> No. Type Quantity Wt.Nol. <br /> X 1. RQ UN1993 WASTE F11XMABLE LIQJZzDS DM P F00 F002 F903 <br /> o N.b.S. ML 'ENE9 BENZENE) 3 P6 I1 <br /> lD001) ' ' ' Dow 223 <br /> w <br /> z 2. <br /> W <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information I <br /> TSDsS.i 82298950 ORI CS84 <br /> 1)ERCaI)128 j t <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retai e y generator confers a ency hgri y <br /> o initial trap o r to it t di 'ori l r r e on a r ori f <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION:. 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 labeledlplacarded,and are in all respects in proper condition for transport-gccording to applicable international and national governmental regulators.If export <br /> Exporter,I cedify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent shipment and am bre Primary <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)lift am a large quantity generator)or (ill am a small qua rotor)is true. <br /> Gene /Offerors PnntetlRyped N H Signatu (Month 0jp�� �Year. <br /> , <br /> V 11 <br /> J 16.International Shipments <br /> 1— LJ ❑ <br /> import to U.S. Export from OS.,' Pon of entry/exit: <br /> Transporter signature(for exports Only): Date leaving U.S.: <br /> 1X 17.Transporter Acknowledgment of Receipt of Materials <br /> Tran 1 PnntetllTyped <br /> oSignature Mea�q Da Yea <br /> a Ce tp". Day <br /> z Tran 2Pnnt Ryped Name Synature - <br /> a4 -'t Month Day Year <br /> r— <br /> Id.uscrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection � <br /> 18b.Alternate Facility Manifest Reference Number.(or Generator) U.S.EPA ID Number <br /> J <br /> f.1 , <br /> LL Facility's Phone: <br /> w <br /> 18c,Signature ofAltemam Faulty(or Generator) <br /> Q Month Day Year <br /> 2 <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 3. <br /> 4. <br /> 20.Designated Facility er or Dperetor.Certification of recei f hazardous materials covered by the manifest ex as note in I <br /> Pnnted/Ty ame t ns Si <br /> 9 Month Day Year <br /> EPA Form 8700-22(Rev.12-17 Previous ed' r o ole � <br /> !l 75e�� � THI SIBILITIES UNDER THE e-MANIFE.STACT. E INSTRUCTIONS ON REVERSE <br /> COPY <br /> E S DE <br />