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ta + <br /> Please print or type:(Form designed for use on elite(12-pitcfi)'typewntec�3 igOiSS7SC 2/2412015 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE.MANIFEST CAL, 0 00 294823 � 1800)4I ?1S Q 0 9 7�q�a'� F L E <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> IRAQ Inc I)SA Rancho San i++ Biel <br /> 1409.5.A4ran way ' <br /> 5tm*toe.CA 95206 <br /> Generator's Phone: (209','992-1"0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CIB?N! 3f�lAI'S ILT1YlrDt"!ii#litRa fiY1!CF!,$PSG. MAD 0 3 9 3 2:2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Hwbors San Jose LLC � C 14 D 0 5 9 4 9,4 `. <br /> 102113emessa Road <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any))` <br /> No. Type Quantity Wt.IVol. <br /> 1 DOiS 349 <br /> . �2 <br /> „H14ARDQtI WASTE.tlfUi66J,€�.tiy.S.,{ liZENE, <br /> X GASIMNELA PQ ili 1 j 4 J <br /> Z : 2. <br /> w <br /> 4 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> i`.CH991943 '11 <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,EPAAcknowledgment of Consent.' <br /> I certffy that.the waste minimization statement identified'in 40 CFR 262.27(a)'(if I am a large quantity generator)or(b),(lf l am a small7quantity generator)jpjVue. <br /> Generator fferor's Printed/Typed Signature Monay ear <br /> -J 16.International Shipments <br /> z ❑Import to U.S. ❑Export from U.S Port of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> U 17.TransporterAcknowledgment,of Receipt of Materials <br /> Trans orterl PrintedlTypedName ignature,�?,y1 / on ay ear <br /> Q Transporter2 Rdbted/Typed Name SignIture Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Qua'nfi ElT ❑Residue <br /> ty Type ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> H18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p' 1. 2. 3. 4. <br /> Hift <br /> 20:Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a s <br /> Printed/Typ Name Signatur�' Month Day Year <br /> A Form 8700-22(Rev.3 05) Previous editions a e obsolete. �` ` " ,/� f DESIGNATED FACILITY TO GENERATOR <br /> Mikan tarbors has the a ro rx 10 P#rm#V for and W41 adept tt:'s 1l the gmeratw4s shwa'.s. <br />