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SSL SK SH14-8nMQ c. <br /> Please print or type. ) /� �� <br /> FormAppraved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2. e o 3. meryggyy Re�pp�ye py�pp�, 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000392595 rV 1—tltltl—%C—1 Tb® SKS <br /> O' Reilly 2785 <br /> 5.Generators Name Mailing Address � Generators Site Address(achieved iered than mailing address)430 <br /> �av <br />' . <br /> 430 Cherokee Ln 39-C-02603 <br /> LODI CA;95240 <br /> Generators Phone: 209-333-71§5 <br /> B.Tr§W9+V fR y SYSTEMS INC U.S.EPA to Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD034322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAM JOSE , CA 45133 <br /> 408-441-0962 CAD054494310 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Co tainers 11.Total 12.Unit <br /> HM rid Packing Gmup(Hany)) - No. Type Quantity WLNol. 13:Waste Codes <br /> o dtfii- <br /> NON-RCRA HAZARDOUS WASTE SOLID, DM P 181 <br /> 0 ABSORBENT AND ( 1156 <br /> W <br /> 9 � <br /> Z <br /> W <br /> b9 � <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additionalinfonnatan TSDeSJ 82353074 RIW4 _ CSS= <br /> 1 <br /> 24Hon -EMERSENCY#800-468-1760-CH/SK/TFI-Contract reta ed by ge�ieramr confers niti ..t- additional ccerg On Dan ra y authori y <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are frilly and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and am 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 EPAAcknooe gment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generetors/Offemrs Pnmted/Typed Name Signature r Mo D y yearll <br /> J 18.International Shipments <br /> r ❑Impon to U.S. ❑Export from U.S. - PnrtofenWxib ! <br /> ? Transporter signature(for exports only): Data leaving U.S.: <br /> C 17.Transporter Acknowledgment of Receipt of Materials ,q <br /> Tra er 1 Printag?yoed Name - J <br /> // Signature' M pay 101 1 �Y/ear <br /> = <br /> Transponder, Pnn d/fyped Name Signature ( 04 <br /> Month Day Year <br /> I- <br /> i18.jisMl5incy _. <br /> 181H Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference <br /> 18h.Alternate Facility(or Generator) Number: U.S.EPA ID Number <br /> J <br /> U <br /> LL Faclldys Phone: <br /> F18c.Signature ofAltemate Facility(or Generator) Month Da Year <br /> Q y <br /> ED <br /> ED <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 / 2. 3. <br /> 4. <br /> 20.Designated Facility Dnepr Operator Certification of receipt of hazarAusmatenals vered by the manifest ex as 'n It <br /> Pnnted(fyped Si r� <br /> EPAForm 8710-22 Re.12-17 Previouseditio sole DESIGNATED`fFACILI[TYCOPY <br /> CIT MANIFEST,Y HAVE RESPONSIBILITIES UNDER THE e-MANS ACT. INSTRUCTIONS ON REVERSE SIDE. <br />