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SSL SK SHIP# 232335245 1111111111 NMI 11111111 <br /> 007766759SK-8 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3. m R e P 14.ManilfstTmeldn <br /> NumUNIFORM HAZARDOUS CAL000392675 1 1 � 0 0 7 7 6 7 8 9 SKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address . Generators Site Address(if different than mailing address) <br /> Ol Reillyy # 2917 <br /> 3226 E Hammer Ln <br /> STOCKTON CA 95212-2814 <br /> Generator's Phone: 972-555-1370 <br /> 6.Trgfflg�Y FSEft SYSTEMS INC U.S.EPA ID Number T.X ROOOOS 1205 <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 /> Fadlitys Phone: BUTTL7NW i LLDW , CA 93206 <br /> 661-762-6200 CAD980675276 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nvl. <br /> 1. Nsm NON—RCRA HAZARDOUS WASTE, SOLID, DIM P 181 <br /> o (ABSbRBENT AND OIL), <br /> z 2. <br /> w <br /> O <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information TSD:BL 44193648 OR 14461 CSG; <br /> 24H EMERGENCY#800-468--1760—CH/SK/Tl"I—Contract retained by generator confers agency authori y <br /> on initial transporter to add or substitute additional transporters an ener ' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aocurateiy described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,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 EPAAcknowl g of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen rotor)or if I am a small q erator}is 1 <br /> Generat&#IfTes Printedrryped Na Sign a Month Day Year <br /> 11 L vot- a <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Pori of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TrquFDrterAcknowledgment of Receipt of Materials <br /> T. r 1 PrintedlTypa Sgnatu Month Day Ykk <br /> O ' �J <br /> tz z <br /> Z T er 2 Pririft!Typed Name Signature o1F Month Day Year <br /> 91 6 :AX13�- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑ a1 Rejection ❑full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ri Facility's Phone: <br /> W182.Signature of Alternate Facility(or Generator} Month Day Year <br /> a <br /> z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes far hazardous waste treatrnent,disposal,and recycling systems) <br /> LLJ <br /> 2. 3. 4, <br /> 20.Design t aciI4 Owner or Operator:Certfi of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Printed Nam Signature Month Day Ye ` <br /> EPt + 17Q0� � 1 �P�@v us editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />