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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZA Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 0 003302982 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ztFiple-IndarFt�t-'+�r�d 4020 <br /> 100 W Vali Road <br /> Tracy, CA 95376 <br /> Generators Phone: 203 $ t: = Y <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ,,leanHarbors Erty A 0 01 ? 93 2 2 2 50 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DpsignatgQ Fa'14 Name and Site Address U.S.EPA ID Number <br /> ',eart A;6Or9"Sar,Jose,LIC <br /> rU2i Berryessa Road CA G + 'a d 4 i 0 <br /> -;ars.lose,CA,it�a133 <br /> Facifity's Phone: 400t t 441_ <br /> ga 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)) 18,Waste Codas <br /> No. Type Quantity Wt./Vol. <br /> cc ft 1'�WSTE BATMPIES-,'*T,FILLED W-TH ACID,1ZLECTR10 p 792 0007 0008 <br /> STORAGE ,9,UN2794,FG III � �� pqo� ��,} 0°506 1 <br /> W <br /> z.NON RRA HAZARDOUS'rTt{AS 6L LIQUIDS,(IJr�OIL):Nr-- (? 934M22f <br /> 3.10N RCRA HAZARDOUS Vk ASTE SOLIDS,(OIL FILTERS),' � � � � 221 <br /> 4. <br /> do <br /> 14.Special Handling Instructions and Additional Information <br /> I. CH:14f76tri9 t r ERG#154 3. CH0X71156 k 30 DT-) <br /> 14 2 C H233t374(vckx ;n P11A <br /> 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, <br /> marked and iabeledlpiararded,and are in all respects in proper condition for transport according to applicable intemationaland nationai governmental regulations.If export shipment and i am the Primary <br /> Exporter,I cer*that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement idendLd in 40 CFR 252.27(a)(if I am a large quantity generator)or( (ifl am a small quantity generator)is true. <br /> GeneratorslOfferors Prinledtryped Nap Signature Month Day Year <br /> � f � Z- <br /> 16.1 <br /> rtemationalShipments <br /> 1— ❑Import to U.S. ❑Export from U.S. Pont of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PdntedlTyped Name Signature Month Day Year <br /> Q Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ResidueJ El Full Rejection <br /> ❑Partial Re ection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> �—� 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> e <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest gxeekpt as noted in Item 18a <br /> P' !Typed Nae Signaturki I Mouth I Day Year I <br /> EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. DESIGINi FACILITY TO GENERATOR <br /> Clean Harbors has the appropqate perTrA5 for ano vAl accept the waste tlrke generator is**Pim, <br />