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P type.( 9 (12-pitch)tyP ) ORDER # dF4�oc <br /> Please print or e. Form designed for use on elitetypewriter.) Fo p veQ 0678 Na 2050-0039 <br /> UNIFORM HAZARDOUS I 1.:Genoralor 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A D 9 8 0 8 8 4 6 1 , 800-535-5053 003512479 J J K <br /> 5.Generators Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> SILGAN CONTAINER CORP. <br /> 1815 NAVY DRIVE <br /> STOCKTON, CA 952Qr� <br /> Generator's Phone 466 <br /> B.Transporter i ComORS61 ame U.S.EPA ID Number <br /> UNIVAR USA INC. C A D 0 0 9 2 5 5 7 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CLEAN HARBORS ;AN JOSE <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE, CA 95133 C A D C) 5 9 4 9 4 3 1 0 <br /> Facility's Phone: <br /> 9a. 9b•U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers ti.Total 12.Unit 13.Waste Cods <br /> HM and Packing Group(Karry)) No. Type Quantity wtNol. <br /> Ce 1 NON—RCRA f3A2ARDOUS WASTE, SOLID, (FLANT DEBRIS) (_ <br /> ;2- <br /> D VA181 <br /> Z <br /> 2•NODE—RCRA HAZARDOUS WASTE, SOLID, <br /> c� (OIL FILTERS) D M JO <br /> 223 <br /> b�uhS <br /> 5� Z <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1. 386878 2. CH30d190 3. tciA301-ACi C3 <br /> PLACARDS PROVIDED BY CARRIER/SHIPPER YES/NO DRIVER, SIGNATURE _ <br /> **** ER CALLER MUST IDENTIFY UNIVAR USA AS RFGI5TRANT **** <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and ara classified,packaged, <br /> marked and Iaboledlplacatded,and are In all respects in proper condition for transport according to applicable Inlemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerfffy,that the contents of this consignment conform to the terms of Bre attached EPAAcknowiedgment of Consent <br /> I certify drat ihpwiste rninimizaWn statement Identified in 40 CFR 26227(a)(If I am a large quantity generator)or(b)Cd I a smell quantify generator)Is two. <br /> Ge rat erors Printed/T S' Month Day Year <br /> �r <br /> r 16.International Shipments <br /> 1- <br /> 11 <br /> 1— L-1 Import to U.S. ❑Export from U.S. Port of entry/axil: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.TransponerAclolowiedgment of Recept of Materials <br /> a Tra porter 1 Prinledryped Name SI alar Month Day Year <br /> 0 Zor�P\ . oS �/ �� a <br /> Transporter 2 PrintedrrypedName 5 rralure Month Day Year <br /> t- <br /> 18.Discrepancy r <br /> I Be.Discrepancy Indication Space El Quentlty Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Atomato Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Li. Facility's Phone: <br /> w 18c.Signature otAllemate Facility or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codas(i.a,,codes for hazardous veaste treatment,disposal,and recyding systems) <br /> LU 1. 2. 3. 4. <br /> Z0.Designated Facility Owner or Operator.Certification of receipt of hazardous maleriais covered by the manifest except as ngted In Item 18a <br /> Priniedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 900121 SHIVS NNVUHHAIH ' Nt3LM301S NV91IIS T996 999 607. YV3 67.:ST 9007/TT/V0 <br />