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State of Colif mia--Environmartal Protection Agency <br />f OMB No. 2050-0039 (Expires 9-30-99) <br />�P1 rbr type. Form deaignd /or we on elite I12-pikhJ"tar185 — 01 <br />1.. <br />F_ <br />3a? <br />V <br />tZ <br />J0 <br />�LL <br />JV <br />Z <br />Z <br />3 <br />0 <br />J04 <br />w <br />Z <br />V <br />Z <br />0 <br />ZZ <br />0 <br />Z <br />ac <br />0 <br />} <br />V <br />Z <br />ac <br />C0 <br />w <br />See Instructions on back of 7e b. Department of Toxic Substances Control <br />I Sacramento, California <br />I <br />UtJIFORAa HAZARDOUS <br />i. Ganeratar's US EPA ID No. Manifest Document No.q61 <br />Page 1 <br />Information in.dta shdd areas <br />Is awntiquired by Federal law. <br />-WASTE MANIFEST <br />In / I2. <br />Q 0 2 9 <br />of 1 <br />3.'Goner atois Name and Mmmg Address ADVANCED INTERCONNEC'r <br />A. State Manifest Document Number 0 <br />P.O. 952 <br />5y5�5,FrFsCp�AsRANEGIE� STREET <br />B. Slate Generator's ID <br />�16 <br />1.eitTRdRAbriYhane I CA 95 3 36 <br />824-111 <br />5. Transporter 1 Company Name6. U5 E ID umbar <br />j rI --r. /All,_T 9 <br />C. Slate Transporter's ID fReserved.1 <br />�f�� V —1 <br />SAFEIW-KL'EEN-'SYSTEMS, INC <br />D. Transportar's Phone <br />7. Transporter YCompany Name ' ' ' - - -- -- -- ' "' - ' 'a. US EPA ID Number ' ' -- <br />E. State Transporter'iiD lRes'e . . <br />'- <br />F. Transporter's Phone _. <br />9. Dafgnald Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />0501440 <br />4 4 0 <br />CLEAN HARBORS SAN JOSE, LL f <br />H. Facility's Phone <br />1021 BERRYESSA RD C 0 9 9411 <br />SAN ;OSE CA 95133 1 1 <br />AAn <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />ii, Unir <br />Wt/Vol <br />_ <br />I. Waste Nam6er <br />No. <br />T <br />a. <br />State <br />_.�3AZARnnttc wAST�.,.�511F TD u...4.-ST--(-GFA'D <br />EPA/Other <br />G <br />�1 <br />_I`iF.Iiii3R�f�-"9--N�+i31i%'%P,C1-"�„�3—{-ErsRbs'1��. 1 <br />E <br />b, _ <br />stat - <br />E <br />NON RCRA HAZARDOUS WASTE, SOLID (WAST <br />EPA/Other ^ <br />R <br />FILTERS) <br />p <br />01 QA <br />D <br />O <br />P <br />T <br />c <br />State <br />, <br />O <br />EPA/Other <br />R <br />_ <br />d. __ <br />Slate <br />EPA/Olher <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes For Wastes <br />Listed Above <br />b. <br />C. <br />d. <br />15. Spacial Handling Instructions agd.Additional Information <br />MFST R T*#10273'2618 0002-3386-59 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />SCORPAUTHORIZERETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents o is Aorwig ment are hs y an accanro y'descri6e v ve by proper shipping name ard. ro classified, packed, <br />labeled, in in for transport by highway h applicable international and national regulations. <br />marked, and and are all respects proper condition according govammant <br />If I am a large quanta generclZ I certify that I haw a progrem in place h reduce the volume and tonicity of waste generated h the degree I hone determined h be economical)r:.- <br />.practicable and that I hove selected the racficabie method of treatment, storage, or disponi tartly available h me which minimizes the present and future threat h human health <br />and dee an jronm mI; OR, if I am a small quantity generator, I have mode a good faith efFo t mi imine my waste generation and select the best waste management method that is <br />evoilable ta me'and that I can afford.' <br />Printed/Typed Name / /� s �7 <br />"1 <br />Signature /'�' <br />lh Day Year <br />! e/F+G. \ <br />T <br />17' "Parnar 1 Ac owled ement of Receipt of Materials <br />Rinld/Typed <br />A <br />R <br />S <br />Na - r = <br />,, <br />ignaror _ <br />dsV <br />PAckrmwld <br />g <br />ement sup,of Mandals - ` <br />RPrinted/TYpd <br />NAno, _ <br />Signature <br />Mondt Day Year <br />E <br />h <br />R <br />19.- Discrepancy Indication Space <br />F <br />A. <br />I <br />L <br />1 <br />20:: Facili Owneror O rater C ,"cation of recai tof hazardous materials covered is manifest a ce t asnohd in item 19. <br />T <br />p/ksfad[Typd Nome' <br />Signature y, <br />Month Day Year <br />Y <br />! F <br />/l <br />PRQL# A)(50002005250 <br />DTSSkFBIs # j9A) 00021172 5 z <br />EPA 0700-22 <br />DO NOT WRITE BELOW'THIS'LINE: <br />B10001949020 Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br />B 3.0002117 211 (Generators who submit hazardous waste for transport out-oF-slate, <br />., produce' completed copy of this copy and send to DTSC within 30 days.) <br />