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SSL SK SHIP# 231943085 1111111111111111111111111111111'11 <br /> D <br /> Please print or type. Form Approved.OMB No.050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. m R s e P 4.Manifest Tracking Number <br /> CAL000393245 1 �--�id�A—�+€'g-1"�'€a SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> , Re i 11 y # 3477 <br /> 420 W Lodi Ave <br /> LODI CA 95240-3423 <br /> Generators Phone 0-09-369-1988 <br /> fi.T`ff fffri'C rrslanuDlane SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONWTLLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-6200 LAD9B0675c76 <br /> Fall Phone: <br /> 9a 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 19.Containers 11.Total 12.Unit <br /> HM and Packing Group(if anyp No Type Quantity Wt.Nol. 13.Waste Codes <br /> NON RA HAZARDOUS WASTE, SOLID, I DM P 181 <br /> o tAB5�1RBENT AND OIL), y+ii� <br /> W/ <br /> Z Z. <br /> w <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:BL 83776856 OR14435 CSG: por,( <br /> 24H EMERGENCY#800-468-1760-CH/SK/TEI-Contract retained goatr cby ao �1A�ay authoriy <br /> on initial trans orter to add or substitute additional trans orters on enerabehalf. <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,and are dassifie4 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 I am the Primary <br /> Exporter,I certfy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I c rdfy that the waste minimization statement entified in 40 CFR 262 27(a)(if I am a large quantitygene r)or(b)(if]am a small quantity generatar)is true. <br /> MUM <br /> Generators%Offemi's PrintedRy Name 'gn re Month Day nnarxYear <br /> la 121,0 /6 ^V <br /> 16.Intemabonal Shi <br /> p_ ❑Import to U.S. Export from U. . Port of entry/exiC <br /> ? Trans ture(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowtedgment of Receipt of Materials <br /> TrTer l Pnntedl Name Signature Monts Year_ <br /> C. lLI7LC <br /> Z Transpo2 Pn edlfyped Name Signature <br /> Month Day Year <br /> 0 Z3 I 2, <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑PaNal Rejection ❑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 /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19,HazardousyVaste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4, <br /> 20.Designs F ty Owner or Operator:Certification of ript of hazardous materials covered by the manifest except as noted in dam 18a <br /> yll Pnnted d /// �ASignature Month <br /> //,�,�/�� Ay� <br /> EPA <br /> 361-22 R�411b25�9605 editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />