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Please print or type.(Form designed for use on elite(12-pttch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS L Gernemnor ID Number 1 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAD078796406 1 866-333-9222 0 0 3 9 3 0 930 FLE <br /> 5.Generators Name and Mailing Address Generators Site Address til different gran mailing address) <br /> St Josephs Radical Canter <br /> 3.800 N California St <br /> Stockton, Ca 95204 <br /> GenereNrs Phone: "to 4AI-1+454 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> Advan+-_ed Chemical Transport - 10AR000070540 <br /> 7,Transporter 2 Company Name U.S.EPA ro Number <br /> 8.Designated Fatality Name and Site Address U.S.EPA ID Number <br /> Clean Harbors of San Jose, TSC (San Jose Pacility) <br /> 1021 5erryessa Road <br /> San Jose, CA 95133 <br /> FaciliNa Phone: 408-441-0962 CAD059494310 <br /> gy 911 U.S.DOT Description Qncluding Proper Shipping Name,Hazard Gass,10 Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity W1.Nol. <br /> t. NA3077, Hasardoa,= Waste Solid, n_o_s., P003 181 <br /> p (Acatone; Alcohol) , 9, PGIII Dm 29 F <br /> � J <br /> - z 2. UN1993, Waste £laRrnable liquids, n.o.s. 000 £003 212 <br /> (Acetone, Methanol) , 3, FGII Il '-- 110 <br /> 1 .'l <br /> .[ 3LAV% (41-3 -01151-e SitJz� SvtK foal cj U IJ pool Doil SS <br /> (` S.tt Pus 'TT N` � � Dr (0 P <br /> Y °ttVl PISS W95fc �.�,ur>>"pc ��d 5oiw{-tangy I D� �0 .� uoo�. Ovo 127- <br /> (� 8 P&2� <br /> 14.Spedal Handling Instructions and Additional Information \ <br /> 1) CH246760 4 -0011 V0)-()f S.5 D r) ; EBG #= 171 2) CH246765; <br /> STC-OA9 I o X 5S c EBG 111- 128 -3) 64A Ste2ri a I 6Tc-- os G�Y.Z OT) <br /> Project Number_ C902115 'M-D e t <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the&ments of this consignment are filly and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and IabeledrplacaNed,and are in at respects in proper condition for transport according to applicable international and nabonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I ceddy that the contents of this consignment conlarm to the frons of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if l am a large quantity generator)or 1(if l am a small quantity genar <br /> for cions PnnlediTyped Name ` ign re on ay ear <br /> c;wh z ah It ` IJP <br /> .� 16.Intemalional Shipments <br /> F Import to U.S. ❑Exportfrom U.S. Pont otenbylexil: <br /> Trans der si nature for exports oN : Dateleavin U.S.: <br /> 17TonsporAcoledmoR ofMatlw <br /> 41 le <br /> T lXpea Name ig Mon ay ear <br /> W <br /> Q ran Aar 2 Printed4yped Name Signaure Month ay Y.5r <br /> nd <br /> F' <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Full Reaction <br /> Manifest <br /> ❑PaNal Reject. <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> a- <br /> FacilitysPhone: <br /> w 18c.Signature ofAlternme Facility(or Generatorl Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,came;for hazardous waste Veaanent,disposal,and recycling systems) <br /> 0 1, 2. 3. 4. <br /> 1 20 Designated Facility Owner or Operator.Certi8callon of receipt of hazardous mater ars covered by the manifest except as noted in Item 18a <br /> PnntednTyped Name Signature Month Day Year <br /> EPA Form 670D-22(Rey.3-0.5) Previous adiuons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />