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SSL SK SHIP# 229572223 11111IIII' '11111I1'I) <br /> Please print or type. 0 0 7 1 $ 0 $ 9 211 S K S <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> 77'1 <br /> HAZARDOUS 2.Page 1 of 3.Em e en Res onse Phone 4.Manifest Tracking Number <br /> MANIFEST CAL000392595 1 1-8`�0(�4gB-1760 SKS <br /> rs Name and Mailing Address Generator's Site Address of ormirentman mailing address) 1` <br /> illy # 2765Cherokee Ln 39—C-02603 <br /> CA 95240 <br /> Phone: 209-333-7195nr 7o p n SYSTEMS INC U.S.EPAID Number� TXR000081205 <br /> 7.Transporter Company Name <br /> CLEAN HARBORS ENV SVC INC. U.S.EPAIDNumber <br /> MAD039322250 <br /> S.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE <br /> U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> 408-441-0962 SAN JOSE , CA 95133 <br /> Faclli 's Phone: CAD059494310 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(it any)) 11.Total 12,Unit 13.Waste Codes <br /> No. Type Quantity WuVol. <br /> c 1.—N8HE' NON—RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> F (ABSORBENT AND OIL), NOR— <br /> W Zj <br /> W 2. <br /> W <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ <br /> 81162620 DR14424 t� hCSC,: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator V fFshipmnt <br /> racy authori y <br /> Ub <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippingare classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemadonal and national governmental regulations.If expand 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 am a small quantity generator)is hue. <br /> Gene toes'OReror's Pdnted/fyped Name Si aNre �� <br /> t � Month Day ear <br /> f 4LcvYtv� cC Li L <br /> 16.International Shipments <br /> f ❑Import to ILS. ❑Export from U.S. Pod of en <br /> = Transporter signature(for exports only): <br /> tC 17.Transporter Acknowletlgment of Receipt of Materials Date leaving U.S.: <br /> 1- T nsporter 1 Printed/Typed Name <br /> a Sign §s� <br /> ' Month Da 1 <br /> aZ Transporter2 it Name / Signa <br /> Month Day Year <br /> 18.Discrepancy 0 I I <br /> Isa.Discrepancy Indication Space <br /> ❑ Quantity El Type El Residue ❑PaNal Rejection ❑ <br /> Full Rejection <br /> 18b.Altemate Facility(or Generator) Manifest Reference Number <br /> U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> Ow 18c.Signature ofAltemate Facility(or Generator) <br /> 2 Month Day Year <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1' 2. 3. <br /> 4. <br /> 20.Designated Facility Ow r Operator.Cert cation of recei azardo s materials covered by the mailma except as noted in Ite <br /> 11I Printed/Typed Name ` Signature <br /> EPA Form 5700-22(R ) ra%M actions re olete. <br /> 1)7361257/40559605 DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />