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Please OrinttVaa. IFnnn drtainnnl hr iwe m de./1 0 <br />UL51UNATED FAGILrWTO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1Gerleramr0 Number - 2. 1 of 3. E <br />. _ -. PeAe mdgerwy Respnse Phone <br />y�' gvun pivrvu. Amo no. <uaruuaa <br />1. Ipst hac7 <br />WASTE MANIFEST 7 - 1 869-333-9222 <br />(�Jy(y�ummbw <br />- 0 2 1 V <br />�+ <br />9 J v 1 FLE <br />5. Generator's Name and deg Address_ :. _ - s SAO Address (d d' ram than Miling address) <br />Central 9allel Waste !eateicee Isae. 1333 E 1is=nez Rd_ <br />PO Dor 2111091,,Lada, Ca:95240 <br />Lodi, Co- 95241 - <br />Genemtor's Phone: <br />6. mnsparter pony <br />U.S.EPAIDNumber <br />ail <br />7. Transporter 2 Company <br />cm <br />U.S. EPA ID Number <br />G t � /fiM,Bo r tom✓ v <br />n� b .� <br />e. Designated adlly Naree aM - <br />U S. EPA ID Number <br />clean Hazbozs of Son Jose, LLC (tea apse Tactuty) <br />1021. Dezzseas■..Road <br />San Jose, CA 93133- <br />Fall' sPhone: <br />9a. 9b. U.S. DOT DMIP11011 (k Wtrlg Proper Shill ft Nervy, Henn Curet, IDNurl6er,. 10. Conteinas <br />11. Total 12. Unit <br />HM arM Paddng G�N(dnY)) Na: Typo <br />Duntly WUV l <br />13. Waste Codes <br />L <br />C <br />0 <br />w <br />2' 0!1263, ='Q WwRta Yadtot, 3, PiZI <br />D00 D03 <br />343 <br />c� <br />DM <br />4�•/ <br />3. <br />salaam, a. <br />1. <br />U.Spedal Handling Instruedormandiliddlonat <br />• +` <br />2) MG 0: 128; CH322832; <br />CEr_-_ t) I <_�I EY6�i23',�) i�i84taF ^•^- <br />r <br />-- -- <br />15. GENERATOR'31OFFEROR'7 COUTTCATN)N: I lyraby declare tlletM mlbnedtNe ouNgxrem era filly arid accyetely descAbed above <br />by ft proper shipping name, and are dassiffed, packaged, <br />marksd aur Iabelkipacarded, end an n ad mopeds M prtpermnd�l to ham ettlOoom4g to aWuble inymaWW and nefidyl <br />govemmentel regulations. M export shipment and I am the Firmly <br />Exporter, f certlly that lalb a <br />co lcaroigmymtonfam y the tarns of dy reached EPAPdcnnnbdgnerrt dCormd. <br />I certify "101 the westeanulim@8tlgn $W~ yen in b CFR 28 a) (Wart a Will quepdy geremlaJ o[ (b) (k I M a sore que nNy genamlor) is true. <br />Genera sNarm <br />Month Uay ear <br />t <br />16.ntematynal Stgpmaas - <br />❑ know te U.3. �Etyat horn U.S. Port denhylexiC <br />J <br />Transporter sifor eaeoon Date leaving U.S.: <br />w <br />17.TransporterPpmoµledgmntotReosiptdMBkriels <br />CTransporter <br />1 yped Name -. <br />a <br />Monthay ar <br />N <br />Q <br />Tmnsporler2 .. .. - <br />n a Y <br />� <br />Q <br />18. DisnWar�q <br />18a, Disaepancylndicadm Space\\ <br />❑ D*dly ❑ Type. ❑ Residue <br />❑ Partlel Rejectlon <br />❑Full <br />Rejection <br />136. Alternate Fadfity (or ('iellBlataf) _ <br />U.S..EPA ID Number <br />J <br />U <br />if <br />LL <br />La.ai <br />w <br />Q <br />Aaemo(a <br />Generated <br />Month Day Year <br />z <br />w19. <br />Hazardous Waste ReportMenagernent Method Coda (ER, Miles tbrhll m "leWremink dispoael, and m ydtrg systems) <br />1. <br />20. Designated FadMy 0" or Operator.CedWt"w of MOW dsTs <br />6doin mdb*t mnrad by dienrnikut ayapt inhenl 188 <br />Print Name IgnaWra 0 <br />Q' • <br />Month Day Year <br />UL51UNATED FAGILrWTO DESTINATION STATE (IF REQUIRED) <br />