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Please odnt or tvoe. (Form designed fnr use nn alita 119.nitrhl tv w-rit- t <br />EPA Form 8700 -22 -(Rev. 3-05) Previous editions are oosaete. DESfGNATED FACILITY TU UtS I INAI IUN S IAI n kir ncwvrnr-uj <br />- <br />UNIFORM HAZARDOUS <br />- <br />1, Generator ID Number <br />2. P19%11114 <br />3. Emergen Response Phone <br />1 vin nppruveu. vmo no. Lu0V-u113y <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />CAL 0 0 0 0 7 8 5 8 1 <br />800 42-9"G`9 <br />008482618 JJ K <br />5. GepVt and Mailing Address Generator's Site Address (if different than mailing address) <br />1624 ARMY COURT <br />STOCKCTON CA 95206 <br />Generator's Phone: 2 0 9 4 6 5- 4 9 1 2 <br />1. T,R&,M6 IRONMENTAL SERVICES INC TRANS U.CEPQIDkI r <br />O 0 1 7 1 0 1 7 <br />7. Transporter 2 Company Name U.S. EPAIDNumber <br />CLEAN HARBORS ENVIRONMENTAL SERVICES INC M A D 0 3 9 3 2 2 2 5 0 <br />8. Dgsjg 9AVs1I e2rA?eAddress U.S. EPA ID Number <br />111xx10�2. <br />1 BERRYESSA ROAD <br />SAN JOSE CA 95133 <br />Facilitys Phone: 408 441-M62 C A D 0 5 9 4 9 4 3 1 0 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WUvol. <br />1. UN 1950, WASTE AEROSOLS (FLAMMABLE EACH NOT <br />D001 <br />331 <br />0 <br />EXCEEDING 1L CAPACITY), 2.1 "LIMITED QUANTITY" <br />1 <br />DF <br />D <br />P <br />i <br />Z <br />2. <br />W <br />3. <br />f <br />4. <br />14. Special Handling Instructions and Additional Information - AerOSOIS <br />jxr,sq <br />5 S HANDLERS TO BE 40HR TRAINED AND USE PPE. <br />15. GENERATOR'SIOFFEROR'3 CERTIFICATION: I hereby declare that the contents of tNs consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeiediplacarded, and are In all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I em the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment 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 erator) is true. <br />eneratoftofleroes PrinledrTypedName Signature <br />Month Day Year <br />S <br />❑16 International Shipments Import to U.S. Export from U.S. Port of entryiexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pdnte&Trypeed Name S' ature Month Day Year <br />O <br />d <br />P�(l- `k <br />QTransporter <br />2 PrintedrTyped Name Sign Month Day Year <br />Ase,14 Fey, <br />18. Discrepancy <br />i8a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />Fr18b. <br />Altemale Facility (or Generator) U.S. EPA ID Number <br />7 <br />U <br />C3 <br />Facility's Phone: Month Day Year <br />18c. Signature of Alternate Facility (or Generator) <br />a <br />Z <br />C719. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />N <br />D <br />1. <br />2. 3. <br />4. <br />20. Designated Faality Owner or operator. Certification of receipt of hazardous materials covered by the manifest except as noled in Item 18a <br />Printed/Typed N e Signature Month Day Year <br />��/ - <br />' <br />EPA Form 8700 -22 -(Rev. 3-05) Previous editions are oosaete. DESfGNATED FACILITY TU UtS I INAI IUN S IAI n kir ncwvrnr-uj <br />