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SSL SK SHIP# 232648097 II I�I�III�II III�I�II I'I II III I I�)III <br /> 007755949SK.6 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page1 of 3. me R e P 4.Manifest Tracking Number <br /> CAL@@@393245 1 - - � - ��@1007758949 SKS <br /> WASTE MANIFEST <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 /> LODI CA 95240-3423 <br /> Generators Phone: 209-369-1988 <br /> s.7r �py�(��cprrp yJyanie SYSTEMS INC U.S.EPA ID Number TX ROQt0081205 <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 BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> Facility's Phone: BUTTONWILLOW , CA 93206 <br /> 661-762-620@ CAD980675276 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> " IISWU—NON—RCRA HAZARDOUS WASTE, SOLID, DM )� P 181 <br /> of (ABSbRBENT AND OIL), 444L <br /> wEv <br /> E <br /> Z 2. <br /> UJ <br /> c9 <br /> 3. <br /> 4. <br /> I V <br /> 14.Special Handling Instructions and Additional Information TSD:BL 84468267 O R 14435C G: <br /> aoo (e- <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers agency authority <br /> on initial transporter to add or substitute additional transp=tersr <br /> ator' s behalf. <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 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 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 minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> General 's/Offeror' Printed T ped Name Signature Month Day Year <br /> 16.Intemational Shi ments <br /> F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> T orter 1 Printed�edde SignatureMonth DYOaZTransporter Printede Sign ure Month Day Year <br /> ` 1 v zz z-) <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 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 /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pr nted ed Name Sign n&i Month Day Year <br /> � O <br /> EP�0,�r�&7coA�t�ev4�-1Z) VE, editions are o solete. DESIGNATED AGILITY TO EPA's e•MANIFEST SYSTEM <br />