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SK SHIP# 225550914 <br />Please onnt or tvne. IFnrm desinnad fir use rm d'da y»-na,-nt <br />006520555SK5 <br />L" r -n o1U„-[ 1— 3- 1 r-ievoueeumonsare wsolele ✓ -DESIGNATED FACJCITYTrSTINiATION STATE (IFOREOUIRED) <br />RECEIN. ; E ru-'* <br />'aUG 9 9 2018 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />- - • -•�-- ---• rurm MpprUveo. 11Mtl NO-ZUJU-UWb <br />UNIFORM HAZARDOUS 1 � Generator ID Number 2. Page of 3 Emergency Response Phone /. Manifest Trxkin Number <br />WASTE MANIFEST f-ALI?17Qt' 1Z'' 006508Q5 (�VC� <br />SKS <br />5. Generator's Name and MellingAddress Generators Sde Address (t diflerem Nan ma�;�ng adtlressi <br />Ftnrli+an Delta Resor', Lir <br />qn.' ghwav 1' <br />rA 95242-00(3, <br />Generators Pnone _'09—::8'-1589 <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />til ;-c-n! ^,vSTEMS INC <br />7 Transporter 2 Company Name U.S. EPA ID Number <br />rtl')1RONMENTAI- SVC INC. <br />B. Designated Facility Name and Site Address Ct-EAN HARBORS SAN JOSF U.S. EPA ID Number <br />16)c 1 BERPYFI39P ROAD <br />Fadi s Phone: <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 />HM <br />and Packing Group (it any)) <br />Ouardry <br />wt./Vol. <br />17 Waste Codes <br />No. <br />Type <br />¢ <br />t <br />w <br />!llttt""" <br />LLJ <br />3 <br />I <br />14. Special Handling Instructions and Additional Information <br />_ 1*2-� 3 95 <br />- <br />n' r r'- c'-� - - <br />15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby detlare that the contents of tcs consignment are fully and accurately described above by the proper s ippng name, aid are classified, packaged. <br />marked and ebel"placarded, and are in all respects in proper condition for transport acoordirg to applicable international and national governmental regulationsff export shipment and I am the Primary <br />Exporter I oerofy that the contents of this consignment conform to to terms of to attached EPA Acxnowledgment of Consent. <br />I certify mal me waste minimization statement identified in 40 CFR 262.27(x) (4I am a large quantity generator) or (b TI am I small quantity generator) is we. <br />Genera s/Oflerors Pdnt yped a Signature k Day Year <br />-.r <br />Z <br />16 Interna tonal Shipments <br />El Import to U.S. ❑ Export him t S Port of enlryrexit <br />— <br />Transporter signature (for exports only): Date leering U S. <br />w <br />t7 TwispwwAckwwfedgmentof Receiptof MateW <br />Trio ter 1 Pnnted(T Name S,gnstur Month Day YY <br />H <br />rensporter 2 F'rin me Signature Month Day Yea <br />18 Discrepancy <br />1 <br />18a Discrepancy Indraborn Space Guarmry ❑ Type ❑ Residue ❑ Partial Re action ❑ Fury RelecW9 <br />Manifest Reference Number <br />J <br />I& Atemate Facility (or Generator) US EPA ID Number <br />U <br />Faaity's Phone <br />W <br />1 Bc Signature of Alternate Facility for Generaoi l Month Day Year <br />Q <br />Z <br />y19 <br />Hazardous Waste Report Management Meted Codes (i.e., codes for hazardous waste treatment. disposal, and recycling systema) <br />G <br />1 / <br />2. <br />3 <br />a <br />20.Designated Facil ty er or Operator Certification of eceipt of ardour materials co y to manifest except Wi now in <br />1 <br />'n Name ignamre Month Day Year <br />L" r -n o1U„-[ 1— 3- 1 r-ievoueeumonsare wsolele ✓ -DESIGNATED FACJCITYTrSTINiATION STATE (IFOREOUIRED) <br />RECEIN. ; E ru-'* <br />'aUG 9 9 2018 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />