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SSL SK SHIP# 225311389 �I�� 1tNII <br /> 006520569$ K5 <br /> Please print or type.(Form designed for use on elite(12-pitch) pewnter.) F�orjm Approved.OMB No,2050-0039 <br /> UINFORY HAZARDOUS i Fara°ID"umber C 2 1 3 1 A00 8468-1760 4 O O 6�"L 0 5 6 9 SKS <br /> 1NAST E MANIFEST AC002951624 <br /> 5.Generators Name and Ma&ig Address Generators Site Address in OfRererd Than maifing address) <br /> Brenkwitz' Michael <br /> 3250 W Kenner Rd <br /> TRACYCA 95304-0000 <br /> Generators Phare: U.S.EPA ID Number <br /> 6.Transporter 1 Canpanv Name TX ROOM 1205 <br /> SAFETY—KLEEN SYSTEMS INC <br /> U <br /> 7.Transporter 2 Company Name /1 n _ .SFPA ID Number <br /> . <br /> port <br /> U.S.EPA ID Number <br /> 9.Desg atedFacliryNameendSieAddess CLEAN HARBORS SAN JOSE <br /> 10 <br /> NJOSE <br /> CA 85133 RYESSA ROAD <br /> 408-441-0962 CAD059494310 <br /> Fed' 's Phone: <br /> 90.U.S DOT DesrnD�(r"y,Proper Shipping Name Hl rd Class.ID Number. 10.Containers 11.Trial V.Unit 13 Waste Codes <br /> HM and Padrrtg Group(d arry)) No. Type Quantity `NVJd. <br /> z X t NA3077 HAZARDOUS WASTE, SOLID, N.O.S. DM P DO 181 <br /> (LEA11), 9, PG III <br /> 4a <br /> z z. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Haralk lnslructlons and Additional Inlormebon TSD-SJ 76718836 ER377,4`60 CSG: <br /> 1)ERG#171• `b V <br /> 24 HR EMEh.=Y #1u800-468-1760 (CH / SK / TFI) <br /> 15. GENERATORWOFFEROR'S CIE TIFI"a":I hereby declare that line cmWj$of mss bonsgnmenl am filly and xaratety desrxtbed starve by the proper sMppng name.and era dasafied,packaged, <br /> n la according to applicable international and national governmental regulations.H export shipment end I am the Prmary <br /> narked and tab liedoararded,and are in al reS08ds in prober Wndiifio NansDort <br /> Exporter.t teddy Nat the contents of Vis corWArent contotni to the tanms of the attached EPAAckrrowledgment WConsent. <br /> nerelor)or(b)(d I am a snail quantity generator)a true. <br /> I cerefY Nal the waste minmvabon statement"do in 40 CFR 262 27(a)(d I am a large quaintly go vonth Day Ye9f <br /> CalJnereke'slO111f <br /> Cdo�rls PdrdeCfyoed New , <br /> ' <br /> a. Ne I"+� r � Z <br /> 16.Infemationel Shipments ❑ImWnDU.S. ❑Exportfran U.S. Port of entryleet. <br /> F Date leavkg U.S,: <br /> Z Transporter signature(for exports ONY): ep[ <br /> W 17.hansWnerAckrwaledgmee'd Of <br /> RRK W of Mebnais Dye 11 Month Day � 1 <br /> TrenspMer 1 PnnledrrYPad`N,a''F'1^x G J.. C`'_ <br /> O J TF1 <br /> EL Month Day Year <br /> Q col <br /> T 2P ypsd Name <br /> of <br /> TC. <br /> jla.Discrepancy <br /> Ise Discrepancy Indication Space ❑Type ❑Residue ❑Pa Ul Rejection Full Rejection <br /> ❑Quentit)' <br /> Manifest Reference Number <br /> U.S.EPA ID Number <br /> 186.Narrate Fachy(or Generetw) <br /> 7 <br /> x1 <br /> LL FaGIMsPltone: Monty Day Yeer <br /> W 18c.Signature d rdterrete Fadlry(a Generabr) <br /> a <br /> H19.HeWdous Waste Report Management Nletlwd Codes(i.e.,codes for harardous rack beatrni diaposai,and recycling systema) 4. <br /> UU <br /> 2 3. <br /> t �it/ <br /> t of materials covared by the me as riled In)tem 18a M <br /> 20.Desgnated Fad a Operator.C 'Rod" Sga <br /> PnnledlryDed Name �. <br /> Pr <br /> EPA Form 8700.221 ) es edNa be. SIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1)8251380/1623725 <br />