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.II+i- an 7Rlin0if IC]i3 .71GItS 111111111 MININNIN <br /> Please print or type. 008343637 sKsForan Approved.❑M$No.205M39 <br /> UNIFORM HAZARDOUS 1,Genu ID Number 2 Pa 1 of 4.Manifest T `� <br /> WASTE MANIFEST CAL1��116.39 1595 1 ��—I� O 08 J`t 3J 1 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(idifferent than mailing address) <br /> O' Reilly # 2?65 <br /> 430 Cherokee Ln 39—C-02603 <br /> LUD I. CA 95e4111211-00W <br /> Generator's Phone: 209-333—t195 <br /> 6. porter 1 ame U.S.EPA ID Numbur <br /> IT+IL; Fxk�dt�l;�l�#5 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SkJL INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ARAGON i TE, L.LC: U.S.EPA I Number <br /> 116W NORTH APTUS ROAD <br /> ARAGONITE , U'!' 64029 !8'0981 <br /> 433--i84-81 17'7 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 71.Total 12.Unit <br /> HM and Packing Group(d any)) 13.Waste Codes <br /> No. Type Quantity MMI. <br /> "UN1993, WASTE FL.i MABLL LIIJUIDS1 � LH4I 3� P 1X11 <br /> (XYLLNE:, K ZF�NE , 3 N i I I <br /> z 2. <br /> w <br /> c� <br /> 3- <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 888760'13 OR 14424 CSS <br /> 1)ER8#128- 2-t0-;3(3 (Do= <br /> 24li �PIL;Y#r {d-4 i-11 --€;Hl i�'f I-I;t ntract retained by generator confers agency authorat <br /> an initiai transporter to gdo or UtStitgte allditional transgorters an generator's twhalf. <br /> 15. GENEPATOR'SKWFEROR'S CERTIFICAMON: I hereby declare float the contents of this consignment are fulfy and axri&a described above by the proper shipping name,and are classifiedr packaged, <br /> marked and fabeledlplacarded,and are in all respects in proper condition for transport according to applicahle intemabonN and national <br /> ExpWer.l oethat the contents of thus cons grur>ent conform to the terms of the attached EPA Aolmowladgnrerot of Consent governmental regulations.If export shipment and f am the Primary <br /> rfify <br /> I car*that the waste minimization statement' in 40 CFR 26227(a)fd I am a large quantity generator)or(b)(dl am a small quantity generator)is true. <br /> Gen for sJOfferors PrintedfTyped Name S <br /> Year <br /> . akwol Shipments <br /> 16Imar: <br /> import to U.S. ❑Export from U.S. Part of entrylem: <br /> Transporter signature(for e)ports only): Date leaving U.S.: <br /> W 17.TransporterAdknowledgment of Receipt of Materials <br /> LU <br /> Tr' <br /> er 1 Prin7�m <br /> Name Sign Moryh Da Y <br /> o a <br /> 4 Transporter ntedlTyped Name S nature <br /> 9 Month Day Year <br /> 9iiC. rt 6 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quaff ❑Type ❑Residue ❑Partial Rejection <br /> El Full Reject on <br /> 18Ir..Alhemate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA!D Number <br /> J <br /> U <br /> U. Facifutyrs Phone: <br /> W 18c.Signature of Alternate Facifity(or Generator) <br /> Q Month Day Year <br /> x <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,dsposa1.and recyding systems) <br /> LLJ <br /> x 3 T- <br /> 20. <br /> Designaaa-tedllFani ty Owner VOjprator.Certification of receipt of hazardous Is covered by the manifest except as noted i 8a <br /> PrintekJlfyped Name Signahrre Month Day Year <br /> 1 <br /> EPA o <br /> 4" f�p . e 2-1Previous editions are obsolete. <br /> I? SIGrfAI'EO F►� ] TO.EPA � <br /> .S ST�SM <br /> �rs . r4 <br />