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Stale of Ca!iForni Emironmenlal Protection Agency '7...Iris-.(j i See Instructions On back r,f page 6. Department of Toxic Substances Conln <br /> Form Approvedi0—a No.2050-0039(Expires 9-30.99) <br /> .Please pr nt er pe. Form designed kr use on elite(IRpi writer. Sacramento,California <br /> Generalofs US EPA ID No: Manifest Docare 2. Pagel Information in the shaded areas <br /> :UN#FORM HAZARDOUS . � is not required by Federal law. <br /> F1 MANIFEST '�� Al j1 of <br /> F3. Ganerabr's Noma and Mailing Address 't 1 A�Stafe Manifest Document Numb r <br /> Ic. B. Slot.Generator's ID <br /> n r %y <br /> n4. Generator s Phone 1 <br /> N S. Transporter 1 Company Name I 6. US EPA ID Number C. State Transport r` ID[Reserved] <br /> C? SAFETY—KLEEN SYSTEMS INC. TXRO000509.30 D: rosporter'aPhoe Ur.) G{,a.:.-,t; ;t) - <br /> 0 <br /> A Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> cn^ I I I I I I r. Tmnspc,Ic,ns Phone <br /> -. Sl Ig Fac;htg;s ID /�. (y - <br /> 9. Designated Facility Name and Site Address 45()T,4 4 10US EPA ID Nember G 9 4JI <br /> Q CLEAN HARBORS SAN JOSE, LL <br /> Z 1021 BERRYESSA RD CAD059494310 H. Facilty'sPhone <br /> `V)� <br /> SAN ,TOSE CA 95133 gr., 545- 3358 <br /> 0110 <br /> .rtes._) 12. Containe13. Total 14 Unit <br /> U I1. US DOT Description lineluding Proper Shipping Name,Hazard Class,and ID Number) No. T rs e Quantity WI/Vol I Waste Number <br /> z NON-RCRA HAZARDOUS WASTE .LxQQUID State 1)2 2 <br /> OTL, NATER, SLUDGE( N0T DOT 1tEGULATED? ' TT G <br /> 3 G , EPA/orhar <br /> d.> � a u f u <br /> N E Is. - state. <br /> m N <br /> m F. EPA/Other <br /> v R - <br /> vA e smt,, <br /> o T <br /> 00 O EPA/Other <br /> - state <br /> W d. <br /> wZ <br /> EPA/Other <br /> U <br /> rtl . H ndlin9 Cade,far Wastes Listed Above <br /> J. Additional Descriptions for Materials Listed sted Above - <br /> 0 a. L.k b. <br /> h 2 <br /> W <br /> m <br /> C. d <br /> Q <br /> Z IS. Special Handling Instructions and Additional Information PirS`C 11 'T 4r.OU U U O OU U U U-001.1 Or.:) <br /> 0 EMERGENCY RESP 800-468—.1'750( 24 HR ) . IF UNDELIVERABLE RETURN TO GENERATOR . <br /> SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br /> W SKDOT# Ac 3287 B1 C: D: <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare tmHhe contents of this consignment are fully and accurablydescribed above 67 proper shipping name and aro classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport 6y highway according to applicable international andnalional government regulations. <br /> IF I am a large quontiy generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a <br /> Flee <br /> licable and that I have selected the practicable method o treatment,storage,or disposal currently available to me which minimizes Ilse present and future threat to human health <br /> to and the environment;OR,if I am a smaquantity generator,I have.made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> W available se me and that I can afford. <br /> $i a Month f)ay,,. Year <br /> �. Pri Ned nolo5 <br /> 8/T sd Na ! _ I y -,. <br /> Z me <br /> W T 17. ran oder 1 Acknowledgement of Recei 1 of Materials <br /> a' A Printed/Typed Name Signature i Month Day Yegc( <br /> flat C.1 5 <br /> �� <br /> LL 0 18. Transporter 2 Acknoveled emeni of Receipt of Materials <br /> 0 T Printed/Typed Name - Signature T ff Month Day Year <br /> NE <br /> A <br /> U 19. Discrepancy lndicotio"pace <br /> Z F <br /> A <br /> C <br /> I <br /> 20. Facility Owner or Operator Certification of rocei f of hazardous materials covered 6y this manifest axce t as noted in Item 19. <br /> T Printed/Typed Name Signature Monts Day Year <br /> T <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A I1/991 Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />