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SIC PPW 1/27}'2016 <br /> Please print or type,(Form designed for.use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> r UNIFORM HAZARDOUS 1 GenpratorIDNumber 21 Pagel of 3 Emergency Response Phone 4,Manifest Tracking Number <br /> SFEMANIFE ,• ,.., , <br /> 3 4 F L EW40 <br /> 5.Gener to Na a Mailin A dress Generator's Site Address(if different than mailing address) <br /> tr t nc�, tta c` u n r+rr <br /> Generator's Phone: (2091992-14G-'- <br /> 4—'- <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ctean Harbors En-oirmar;ent-ai SeryaG�:;,"c_ Mt iii D 439322250 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name.andSiteAddress-- U.S.EPA ID Number <br /> Olean Harbors San loss LLQ: <br /> 1021 Berryessa Road- CAV 0 5 9 4 9 4 3 1 0 <br /> S.art.Jose.CA 9fji33 <br /> Facility's Phone: A1121 441AM7 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1 NA30912,HAZARDOUS WASTE.LM D.N.0-S..(BENZENE, Q(}133 343 <br /> a iA9t]E#ttk7,S.PG t#i t. / �� �� <br /> UJ <br /> w", fi* ,'� <br /> 3n z. d <br /> 9 <br /> / 14.Special Handling Instructions and Additional Information <br /> I-c85.91942 S' ERGi 171 <br /> 2'- H991945 C p <br /> EA '19 2 - <br /> 5. GENERATOR'S/OFFEROR'S CERTIFICATION:_hherebydeclare that the.contents of this consignment are fully and accurately described above by the proper shipping name and are classified,packaged, <br /> marked,g') 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 /> Exl�t0'Uf 46tthe'contents of this consignment conform to the terms.of the attached EPA Acknowledgment of Consent. <br /> hcemftf�atrjFreWaste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator�:or(b)(ill am a small quantity generator)is true,., <br /> Genera tors(OfferoraPnnted yped Name gnature i Month Day ear <br /> J 16,International Shipments — <br /> El Import to U.S. ❑Export frofnal.S,. Pfoff of en /exiit: <br /> z <br /> Transporter signature for exports only): date leaving U.S.: <br /> UJ 17.TransporterAcknowledgment of Receipt of Materials <br /> Transpe 1 Printed/Typed Name Signature �� Month Day Year <br /> CY <br /> QTransporter 2 Printed(fyped Name Month Day Year <br /> F- <br /> 18.Discrepancy — - <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type yp El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Phone: <br /> Lo 18c.Signature.of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method.Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3 4, <br /> A 141 <br /> 20.Designated Facility Owner or Certif�)aionof receipt.of hazardous materials covered.by the manifest excep�,as noted in Item l.8a f ,, <br /> Pnnte^�d[Typ( Name Signat�,`��. /`:' / /f' Month Da Year <br /> EPA Form 8700-22(Rev,.3-05) Previous editions afe obsolete. / / DESIGNATED FACILITY TO GENERATOR <br /> Cie-on Ha6crrs has the avorepinate pemits€ar and will-meat the waste the t -oiler-gar sb#pOR-a- <br />