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SSL SK SHIP* <br /> Please print or type. S 7 7 q . Form Approved.OMR No.2050-0039 <br /> UNIFORM HAZAROOUS> 1,Generator ID Number 2.Page 1 of 3.Emargen sponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ,Cf�L@@@393245 1 1—tl@ —468-1760 (��[(� <br /> S.Generator come and Mailing Address Generator's Site Address(if different than mailing address) Vr`�7 <br /> O' Reilly * 3477 <br /> 420 W Lodi Ave <br /> LODI CA 95240-3423 <br /> Generators Phone: 209-369-1988 <br /> 6.Trans dere Comany Name US.EPA ID Number <br /> OFETY (LEEN SYSTEMS INC TXROOOO81205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. <br /> 8.Designated Facility Name and She Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> Facility's Phone: SAN JOSE , CA 95133 <br /> 408--441—@962 SAN <br /> 9a 9b.D.S.DOT Description(including Proper Shipping Name,Haram Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> K <br /> roe0 <br /> tiDow <br /> z z. NON RCRA HAZARDOUS ASTE SOLIDS DF P 181 <br /> ({BRAKE SHAVINElSI,�NfA---� ' <br /> 3. WjNON—RCRA HAZARDOUS Wl SOLID, OM P 181 <br /> (ABSORBENT AND OIL)9 -WIl— <br /> 4. <br /> 14.Special Handling Instructions and Additional ntonmation TSD:SJ 82090450 OR14435 GSSG <br /> 1)ER6M128 � � <br /> 24H EMERGENCY*800-468-176@—CH/SK/TFI—Contract retained by generator confers a ency authority <br /> nn rini+ria 3-15. GENERATOR'SIOFFEROR'S CER IFICATION: I hereby declare that the contents of this ocnsgnment are fully and accurately described above by the proper shippin name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all raspams in proper omsdition 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 minimizatbn statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) am a small uarmy generator)is true. - <br /> Genershor'sl0r'Prin d/fyyped Name, �.` Signal 4til— - Month Day Year <br /> +kln! 1 A /1 ' 2 <br /> 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexh: <br /> ? Transporter signature(far exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tre sponer 1 PnntedrTyped Name ' Signa Month Day Year <br /> 0 <br /> QTransporter 2 PnntedRyped Name / gnatum Month Day Year <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejecton ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature of Aktemate Feality(or Generator) Monts Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes li.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LIUI <br /> 1 2. 3, I 4. <br /> 20.Designated Facility tor:Certig bn of 14�of hazardous materials covered by the manifest except asnoled in Item <br /> Pdnledrryped Name r Signature Moyes Dy Year <br /> FPA Form 8700-22(Rev. revious editisa ete. DESIGNATEDFACILITY COPY <br /> 1/r',oV HMA'N�I' (�`�1FJI�YE �SPOIEIY��HM (FEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE. <br />