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pie Fe pent or type.(Farm designed for use on elite(12-900)fypewntac��17029134i26-002 9C PPW 5/30/2017 <br /> Fnfm Approved.OMB No 20SW39 <br /> UNIFORM HAZARDOUS 1 Gene alof iQ Number Tj <br /> age 1 of 3,Emerger�Response Phone 4.Alanifjjac$fng Number <br /> WASTE MANIFEST CAD 9 8 3 G O 0 5 9 4 800 483-3718 011�(UJ�8 2 2 FLE <br /> i Czealatofs me and Maili Address GAddress(if eneratods Site Addrdnlen+nl than mailing address) <br /> F atser <br /> 7373 West Lane <br /> Sticakton-,A 95268 7373 W@St Lane0108446 <br /> Generator`s Phone Q09147"966 ATTNJessitaCwam StoCMUM•CA95210 <br /> F Iansparer I UrPpany Namu <br /> CleanHarh01SU.S EPA 10 Number <br /> Ea++R+f�iiSerrioes,Its MAD 0 3 9 3 2 2 2 5 0 <br /> T <br /> :I:! ::;:nsprrleI 2 Company Name <br /> U.S.EPA ID Number <br /> 8 Designaled FaQlily Name and Site Address <br /> Clean Harbors San Jose LLC SEP I U.S.EPA ID Number <br /> 1021 BeMessa Road LTH CAD 0 5 9 4 9 4 31 O <br /> San Jose.CA 95133 Ertv4RONMENTAL HFJ� <br /> Facility's Phone. MIM 441=O.VA2 <br /> PERp.I}4T15ERV10ES <br /> 9a 9b.U S DOT Descripbon(indudmg Proper SWppng Name.Hazard Crass,ID Number. 117-COnlainers <br /> HI,A and Packing Group(if anyl) 11.Tout 12,Unit 13.Waste Codes <br /> 1 NO_ Type Ouan111y W Nd. <br /> Ix UN MO.WASTE AEROSOLS,RAMMABLE,(EACH NOT <br /> X EXCEEDING i L CAPAIII21 0 01 OF 00009 P D0 <br /> 0i 55i <br /> w <br /> z 2. <br /> UN1950,AEROSOL$.NON41AWIiABLE,(EACH NOT 551 <br /> x EXCEEDING i L CAPACITYI.2-2 001 D F 00006 p <br /> 3 <br /> UK 3028.BATTERIES,DRY.CONTAINING POTASSIUM <br /> X HYDROXIDE SIDUD.8 001 D F 00012 p 181 <br /> NON-RCRA HAZARDOUS WASTE-MILIDS.OL RLTM 001 OF 0 0 0 0 P 352 <br /> 14 Special Handling lrnbuctions and Addibonal Information <br /> 1.Il 1112 6 1X10 FLEET65"7 <br /> 2_LrCCRQ12 6 1X5 <br /> 3-CFiB 43 8 0 9 ER 4 1X5 <br /> 15 CENERATOR'SlOFFEROR'S CERTIFICATION; 1 hereby dedere that the contents of III consignment are fully and accurately described above by the proper shipping name,and are dassa ,padraged, <br /> marked and Wbeied(placarded,and are in all respells in prWer condition for transport according to applicable intemabonal and natural gowmmeqju <br /> Exporter,I certify that the oontenks of chis consigrmient oonform to the reacts of the attached EPAAdvrnwsedgmenl 01 Consent. fegulations,If export sh p nail and i am the Pr mart' <br /> I off*umt the waste minimlaetion statement identified in 40 CFR 262.27(a){if I am a law quartity generator)or(b)(d I am a small quantity generator)is truq. <br /> o efpds VrifilediTyped Marne <br /> Nil Year <br /> 16.international Shipments <br /> Z C Import to U.S E Export from U.S. od of entryfexii:_. <br /> Transporter s'nate for ex oni : —i-_ <br /> C 17 Transparlef AdToMedgr�enl of Recepl of MatenaLs Dale 4ewno U,5.LU - <br /> 1W <br /> ce F4xrTef 1 Pnrtedriyped Name <br /> O f•�� ./J or ay ear <br /> Z Trarspodpr 2 Printed.?yped Name gnalure <br /> .201 <br /> ant ay ear <br /> F <br /> 18.Dscrepancy <br /> 183.Discrepancy Indication Space dca vt ty Q Type <br /> Residue 0 Pallial Rejection ❑Full RejecBon <br /> 18h AJtomale Fapliit'(or Generator) Aiarufest Reference Number <br /> EPA1D Number <br /> U <br /> Q <br /> LL Fadli 's Phone: <br /> WI ac Signature of Alternate Farifity(or Generator) <br /> Month Day Year <br /> 0 19.Hazardous Waste Repan Managemenl Method Codes(i.e.,codes for hazardous waste treatment disposal,and ecydir g system)W 1 <br /> C} <br /> 3. 4 <br /> 11141 11141 H141 Hi41 <br /> 20-Desrgnaled Fa"ty Ehmer or Operator Cartixabon of recei t of harardorfs maberiais by the manifest ex noted n Ilam 18a <br /> Signa <br /> PrinledfTyped Na tu <br /> nth Llay year <br /> Jam` <br /> EPA 18700-22(Rev.3-05) Previous editions re obsole <br /> Clean Nabors has thea a NATE ACILfTY DESTINATION STATE(IF REQUIREI <br /> app petits hr and w61 areept the waste the ■r is shipping. <br />