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SSL SK SHIP# 259217427 ��IIIIIIII' I�� fln� ". <br /> 00T1b1905SS <br /> Please print or type. K <br /> Form Approved.OMB No.2050-0039 <br /> i.Generator ID Number 2.Page 1 of 3.Eme en ResEonsa Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAL000393245 1 I e 0a-418-1760 (SVS <br /> WASTE MANIFEST IQQ7181 9f)5V 1��7 <br />- 5.Genemtors Name and Mailing Address Generators Site Address(if different than mailing address) <br /> O' Reilly # 3477 <br /> 420 W Lodi Ave <br /> LODI CA 95240-3423 <br /> Generators Phone: 209-369-1988 <br /> 6.Tens oder 1 Eomy�any Name U.S.EPA IO Number <br /> Sf�FETY—t4LEEN SYSTEMS INC TXR000081205 ' <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD0393222250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408-441-096'2 CAD059494310 <br /> Facility's Phone: <br /> 9a, 91h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.WBale Y <br /> HM and Packing Group(if any)) No, Type Quantity WI.NoI. <br /> NON RCRA HAZARD0 WASTE SOLIDS, OF P <br /> a0¢ (1313ME SHAVINGS), <br /> w 2 <br /> w <br /> c7 <br /> 3. <br /> i <br /> 4. <br /> 4.Special Handling Instructions and Additional Information TSD:SJ 80852719 0R 14435 CSG: *� ' <br /> J�1)��ZI I <br /> 24H EIERGENCY#800-468-1760—CH/SKiTFI—Contract retained by generator onf s a ency authors y� { <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ab 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 l am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. y <br /> I taffy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quanTy generator)is true. i <br /> Generator es Printed/Typ Name Sig tura Month Day Year { <br /> 6 <br /> J 16.Intemamonai bripmentai 11 <br /> Import to U.S. ❑Expert from U.S. Port of entry/exit: 5`f <br /> = Transporter signature(for exports only): Date leaygU.S.: <br /> W 17.TransporterAcknowledgirrent o Receipt of Materials <br /> Trenspo rinnted/Typed in Signature Month Day Year <br /> O <br /> a <br /> 71 <br /> Z Transporter 2 Pnntedff me signatIrb 9ft Day 4aar <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanti Residue + <br /> ty El ❑ ❑Partial Rejectlon El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u Facilitys Phone: t <br /> yOj 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> 6 j <br /> 2 <br /> y19.Hazardous Waste Reflod.1yanagernent Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility er o Ope oc Cedifica of M of azandous materials covered by the manifest except as note 18a <br /> illl Printed/Typed Name Signature ' M J D r ' <br /> EPAForm 8700-22 Rev.12-1 evious edition are DESIGNATED FACILITY TO EPA's e•MANI EST SY T <br /> 1)73684:�J6451 1 <br />