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S91_ SK SHIP# 231953214 1111111111111111 llllillll 11 lilt l 111 111 <br /> 007313714SKS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. me R e P 4.Manifest Tracking Number <br /> WASTE MANIFEST CAI-000392595 1 `� —+ —1"n0 007313714 SKS <br /> 5.Generator's Name and MailiAddress Generator's Site Address(if different than mailing address) <br /> O'Reilly # ?765 <br /> 430 Cherokee Ln 39—C-0603 <br /> LLD I CA 9540 <br /> Generator's Phone: 209-333-7195 <br /> 6.TrpRrglVmp�yEelacpg SYSTEMS INC U.S.EPA ID Number T i(R00t3081205 <br /> 7.Transporter 12 Company Name 0, U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW I LL.OW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , CA 93206 <br /> 661-762-5200 CAD980675276 <br /> Facility's Phone: <br /> 9a 91b.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.Nol. <br /> 1 NON—RCRA HAZARDOUS WASTE, SOLID, DM .3o0 P 181 <br /> o (AB96RBENT AND OIL), 'tJM <br /> w <br /> Z 2. 3 <br /> w <br /> 3. <br /> 4. <br /> x' <br /> 14.Special Handling Instructions and Additional Information TSD C BL 93649419 OR 14424 CSG <br /> 24H EMERGENCY#800-468-1760—CHISK/TFI—Contract retained by generator confers aggency authori y <br /> on initial transporter to acid or substitute additional trans orters on enerator' 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 /> GeneratoeslOfferor's Printed/Typed Name Signature Month Day <br /> 36 <br /> 1CP� A'L- -0 ^ VILM 7 <br /> 16.International Shipments <br /> � El import to U.S. Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Tr sporter Acknowledgment of Receipt of Materials <br /> w / Month Day Year <br /> T n o er 1 Pr Hied d Name Signatu <br /> Ix <br /> o �© <br /> H �� Month Da Year <br /> Z Transporter Printed/Typed Name Signature y <br /> e ! 4 Osl <br /> W 6 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> lai Facility's Phone! <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZZ <br /> 11 <br /> N19.Hazardou aste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> J 1, / 2. 3. 4. <br /> 6W <br /> 20.Design d F ility Owner or Operator:Certification of re ipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed e e �'/�. / Signature Mo Day <br /> EPA Form 8700-22((Rev.12-17)) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)7361257140559605 <br />