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Af <br />SSL SK SHIP# 224674283 N k "'kj <br />Please print or type. (Form desianed for use on ellen 112-narh) wnnwHm i <br />� --1 111111111111111111111111111111111111111 <br />006461764SKS <br />21-7582Y36P9S8297 Utbl(LiNATE11 F�kCILITYTWDESTINATION STATE (IF REQUIRED) <br />���s1�"6 N. MmMestT a F i ii proved. OMB No. 20500039 <br />UNIFORM HAZARDOUS 1. Genareta ID Number CAL000393929 2 1 1 1' E�� u <br />WASTE MANIFEST <br />�" <br />r 00 ��T 6 4 SKS <br />nerato <br />5. Gers forme <br />and Maiing Address Generators Site Address (it different Man madkg address) <br />W <br />W1 rrhau5er e <br />2700 S California St <br />STOCKTON CA 95206-0000 <br />Generators Phone 209-373-8256 <br />6 O 1)�Rft "SYSTEMS I NC US EPA ID <br />Number T x ROOM 1205 <br />1.6- 2 Can ny Name U.S. EPA ID Number <br />CLEAN HA�BORS ENVIRONMENTAL SVC INC. <br />MAD039322250 <br />B. Desgneled Fadkty Name and Site Address CLEAN HARBORS SAN JOSE <br />U.S. EPA ID Numbs <br />1021 BERRYESSA ROAD <br />408-441-0962 SAN JOSE , CA 95133 <br />Facie s P pro CAM9494310 <br />5a. <br />U.S. DOT Desatpeon (inducing Proper SNpping Name, Hazard Class, ID Number, <br />10. Containers <br />HM <br />and Packing Group (if any)) <br />t <br />11. Total <br />Quantity <br />12. Unit <br />WI.Nol, <br />13. Waste Codes <br />No. <br />Type <br />O <br />0 <br />W <br />= <br />NON RCRA HAZARDOUS WASTE SOLIDS , <br />COP�ER AZOLE TREATED LUMBER), <br />DM <br />P <br />181 <br />�VV <br />3. <br />4. <br />16. Spenal He g Inshvctlonl�s-7a"Sn—d`'Addibnal IMonn(er�Gon PTSD a SJ 76061017 WE25333 CSG: <br />IV t <br />-J' <br />`� _ (O(Da <br />24 HR RGENCY #1-800-468-1760 (CH / SK / TFI) <br />AUTH AS "AGENT—FOR" BY GEN TO RETAIN <br />LICENSED SUB CARRIERS AS NEC <br />15. GENERATOR'SIOFFEROR'8 CERTIFICATION: I hereby cedars that the contents of M5 consignment are fully and aommmly described above by the proper shipping name, end are classified, packaged, <br />marked and labeledrplacarded, and are in all respects in proper condition for transport according to applicable international and national gr v merNal reguiatlons. If export shipment and I am Me Primary <br />Exporter, I catty that the coolants of this consignment conform to the terms of ff. attached EPAAcknowledgment of Consent_ <br />I certify shat the waste minimlzaoon mart In NO CFR 262.27(a) (if I am a large quantity generator) or (b) (d I am a mail quantity generator) is true, <br />Generators/OM P-.ted/i a /-I—� Signa re Month Day <br />JYepar <br />12-11 /O <br />16. Ince abo,al Glx% <br />❑ Impod to U.S. <br />I E from U.S. Pori of entry/exit: _ <br />Transpolar sgnaNre (for expo only). Date leaving U.S.: <br />17. Transporter Admowledgmenl of Receipt of Materials <br />T.Poor 1 Pnnt d Neme Signature Monts Day Year <br />Z� <br />a <br />n <br />0. ), E' l3 7 <br />Q <br />r— <br />Tran tedrfyped Sgnatue Monts Day Y <br />Y <br />♦ <br />16. Disaepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Residue El Partial Rejection LJ Full Rejection <br />Manifest Reference Nanber: <br />18b. Niemela Facility (a Generator) <br />J <br />U.S. EPA ID Number <br />U <br />toai <br />FiiAltv's Phone <br />1&. SignaNre of Ntemate Facility (or Generator) <br />F <br />a <br />Month Day Year <br />2 <br />y <br />19. Hazardous Waste Report Manage nt Ihod Codes (i.e., codes for hezafdous wast he Invent. disposal, and r ecyding systems) <br />0 <br />1 <br />2 <br />JOVI <br />3. <br />a. <br />1 <br />20 Des gnaled FaaLty, er or erator Certification of receipt of hazardous materials cave by the manifest except a ad i 1 8a <br />Pante y Name SignaWre Month Year <br />/Day <br />UZ <br />EPA Forth <br />8700-22IR-9-051 Previnuc eew,�.,< o.e,.r,�„ier., <br />21-7582Y36P9S8297 Utbl(LiNATE11 F�kCILITYTWDESTINATION STATE (IF REQUIRED) <br />