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Piease print or type.(Form designed for use on eilte(12-pitch)typewriter) T ;1.9',`:6 617 Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Gereraln"je 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number 1 WASTE MANIFEST : g R ��4 •. U u i u J o V 5.Generator's Name and MailingAddress Generator's Site Address(if different than mailing address) Femp#e-1 nhif,a P faro*u 4 a PO Box 1029 400W Vmica Road T'rVCV, CA 9531178 1'trv,, CA .9537t, Generator's Phone: f19 q';A_j ; :7PI:{"ebb4'�4l ref 6.Transporter 1 Uompany Name US.EPA ID Number I N)*;uai`aier*ice s Inc 7 Transporter 2 Company Name U.S.EPA ID Number 8. ignatt Faglity hi' and Site Address U.S.EPA ID Number - - 1fat#�nrFt Jose t1' 1021 Rerryessa Poad � �+ t 1 u � G 4 M � s s G San Jose,CA,Q5135 Facitity`s Phone: ga go.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt./Vol. a 1' NONE,N&I RCRA HAZARDOUS V ASTE SOLIDS,(C#L FILTEWF u, 2. 3. 4. 14.Special Handling Instructions and Additional Information t GHa%71135 ('✓r 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, marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicabl2 international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generiator's! ero sPrint yp Nptne lgn2lure on ay ear t �-tir1 5 )t'A1T1# ( s r 9 .y'. j 116.International Shipments F ❑Import to U.S. ❑Export from U.S. Pod of entrylexil: Z Transporter signature for exports only): Date leaving U.S.: 17.TransporterAcknowledgment of Receipt of Materials Li TransporigirP Aedfryped Name ignatu � on ay Year �- re- I Z Transporter 2 Printedffyped Name Signature on ay ear t- 18 Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue LJ Partial Rejection ❑Full Rejection Manifest Reference Number, H 18b.Altemate Facility(or Generator) US.EPA ID Number U 4 LL Facii' 's Phone: W lac.Signature ofAltemate Facility(or Generator) Month Day Year 4 Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ,n 1. ) ...F. 2.-- T 4. H 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Ppntedfryped Name Signature Month Day Year _ EP-Pr N j�05) Previous editions are obsolete. 3f FCS VA MCCept 04 y t;tp tt�4� craw 1s ria DESIGNATED FACILITY TO GENERATOR