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Please print or typE. (Form designed forum on elite 112 -pitch* writer l <br />orm - ( ev. -05) Previous editions are obsolete. <br />DESIGNATED FACILITY ilKIDESTRNATION STA JIF REQUIRED) <br />.• v v — — rOrm .vpprov <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Energen 7Response Phone 4. Manifest TracMng Number <br />:. UMN No. 2050-0039 <br />WASTE MANIFEST CllL000194471 `l 888-785-7225 0039313' <br />4 FLE <br />5. Generator'sNret Mailing Addl9ys Generators Site Address (itamerent than mailing address) .. <br />Centra Ya el caste SerTices lac <br />1333 E Tomer Rd_ <br />Lodi, Ca_ 95240 <br />Generators Phone: Inv aii SAi16. <br />mnspoder I Company Name U.S. EPA 10 Number <br />—` <br />Adwaaced Che�ieal Transport C711Z000p7 <br />$40 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />Clean Harbczs Emirerrmtal Sar ices, =ne_ K1111100039322250 <br />8. Designated Faclity Name and Site Address U.S. EPA ID Number <br />Clean Hasbozs of San Jose, LIC (San Jose Facil:il <br />1021 Herryessa Road <br />San Jose, CE 95133 <br />Facilitys Phone: 408-441-0962 CBD059419 <br />ILO <br />go. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />12. Unit <br />HM and Packing Group (t any)) <br />Quantity <br />13. <br />Waste Codes <br />No. <br />Type <br />o <br />1. UN1263, Waste aunt, , <br />DO 1 <br />35 <br />343 <br />z <br />' <br />P <br />w <br />z <br />3. <br />4. <br />14. Specal Handling Instructions and Additional Information <br />1) ERG 0: 126; CH322832; CEC-p(il j� 'S CT) <br />J' <br />Project luuz: 0402612-03 <br />15. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are clas <br />their, packaged, <br />marked and labeledlplacanded, and are in all respects in proper condition for transport according to applicable international and natonal governmental regulations. Nexport shipment and f <br />I the Primary <br />Exporter, I certify that the contents of this consignment mmomn to the terms of the attached EPA Acknowledgment of Consent <br />I cerdly that the waste minimization statement identified in 40 CFR 262.27(a) (t I am a large quantity generator) or (b) if I am a small quantity generator) is true. <br />enerato emrs not yame signatunanoni <br />Uary Year <br />itole <br />I I <br />J <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Ezport from U.S. Part of enhy/exit: <br />Transporter sinature for exports on : Date leaving U.S.: <br />w <br />17. TranspoderAcgpvdedgment of Receipt of Materials <br />IE <br />Tre porter Print ypetl Name Ig a re ' n <br />q►� d <br />ay r <br />QTrensporter2 <br />Printed(Typed Name 619nalum <br />Day Year <br />} <br />16. Discrepancy <br />18e, Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑ <br />'Full <br />PaNal Rejection <br />Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />U <br />a <br />na <br />Facili sPhone: <br />y�j <br />18c. SignaNre ofAlremate Facility (or Generator) <br />Mm <br />' Day Year <br />f.. <br />Q <br />2 <br />W19. <br />Hazardous Waste Fool Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />3. 4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as ill Item IBe <br />PdntedRy Signature moo <br />r L <br />I Day Year <br />EPA <br />F 8700-22 R 3 <br />/ <br />orm - ( ev. -05) Previous editions are obsolete. <br />DESIGNATED FACILITY ilKIDESTRNATION STA JIF REQUIRED) <br />