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i - <br /> TSCr P•0•Dox 400, Sacramento,CA 95812.0400 within 30 days* <br /> to:n <br /> ..Generator,mail a Copy Form Approved.OMB No.2050-0039 ` <br /> 9Wdlsr, sephp,ro 4.Man tTncklnq NumO r O �� <br /> Please Print or type.(Form des ned for use on elite 12 pitch typ ) 2.Page 1 of 3.Emergency R6spon an 0 <br /> 1.Generator LD Number v y <br /> UNIFORM HAZARIJ IU3 op 4 lh 6 1 C.• . <br /> WASTE MANIFEST 4-rIR{� f GeneratorssiteAddrasa{Ud'dferentthanmallinguddreas) <br /> 5,Generators Name and MaUingPddrass C " a <br /> •l� 1```o AV+o P Lw7.a R' <br /> © -g32,0 <br /> 32,02,690 <br /> ICS+ © U.S.EPAIDN <br /> zurato'r+�'hdKe:�� L 3282 <br /> e.Transporter f Company Name _. <br /> I U.S. PAID tmn r <br /> Ever reen Environmental Services MAD039322250 <br /> TT a 2 Company Name <br /> Clean Harbors Environmental Services,Inc. U.S.FPA ID Number ' <br /> &Designated FacOUy Norma acrd Sitd Addrass an Jose,LLC CAD059494310 <br /> Clean Harbors S <br /> 1021 Berryli Rd.,San Jose,CA,95133 <br /> 408-451-5000 <br /> Facill s Phone: 10.Containers 11.Total 12.Unit 13.Waste Codes i <br /> Sh' Name,Flazerd Gass,ID Numb6r, No. Type Men% WtNd. <br /> Ba. gb.U.S,DOT Descn ptlar(fndrxfr 1`g�ePar rPA <br /> HM and Paddng Group(K any)) n 331 D001 _ <br /> X 1' UN1950, WASTE AEROSOLS, 2.1, (Ltd. Cry.) <br /> o l I <br /> 2. i <br /> I <br /> 3. j <br /> I j <br /> I i <br /> i <br /> 4. <br /> IHe <br /> 14, P7J395 8 389 . <br /> asini ndJrrg InsUucEona and Ad it sell Intormadon <br /> 9S1) ProfilD#CH430538,D}�0#128 .KD <br /> 3CY9.7 <br /> 7 Y Q� descdoed aba+a by 11 s grope stMPPInA Home noel are dassltfed.4adutged i <br /> declare Urat ihs aonients of UJs consVgnmont are fugy end xaralely ulaUans.K export shipment and I am the pr mart' <br /> 15. GENFRATOR'SIOFFEROR'S CERTIFICATION:I hereby aocording to applloable Inlemational and national govemmenlel req <br /> marked and tori eledlplacarded,and are In td4 respells In Proper conddbn for aenspo< <br /> that the contents of Ws consignment conform 10 ft terms of the abated EPAAckr v�ed0rnent Cdl�am a am cub ty generator)is true. Mon Ds ear <br /> cxparter,V catUfY an nerev)or );' t <br /> I eoitlfy Ihat Pte waste mla;mIzaten statement Idended in 40 CFR 26227(a)(K i am a 181`96 4u RY Slone <br /> Genorato U a PdritcdlTy�ed " <br /> I ❑export ham U.S. at o !exit: <br /> 16.Mematlano S pments Impolttous. D avingU.S.: i <br /> Transporter slgnatura(foroxPoft only): M "p a r <br /> 17.Transporter Acknowledgment of Recefptof Maferlels Sign6turo L/ <br /> Trans <br /> O rt P ntadTyped sone /�a <br /> GLJ Month Day Year <br /> a Signature <br /> 0 Transpoder 2 Pnn�dffyP6 cora �.- <br /> �I El Fu11 Rsieotlan <br /> 18.Dlsaepanay ❑Residue ❑Partial Rolectbn <br /> f 188,Dlscreparrc/ImJfrsUon Space � 4,ranUiy <br /> Mai Reference Numtxx U.S.EPA 10 Number <br /> f Blo.tdternate Fadgy(or Generator) <br /> onth Day Year <br /> Facltity's Phone: <br /> 18c, 9nature o Pftemale a1`Ky(or Galwator) II <br /> 10.Hazardous Waste ReportManagameM IvleUrod Codes(I.a.,codes for hazardous waste treatment,disposal,and recycling sysl6ms) 4 I <br /> or operator.CertfffCfCatbn of receipt of hazaruJ <br /> dous rneted6is covered by <br /> the marge6t except as noted In'Kem 1 air <br /> 20.Des'Igrated Faalffy Oxmsr Fa afuro t <br /> Fd t ype Name e I <br /> EFA Form 700 22 ev. A5) Prerotls iti s are obsolete. D SIC, i i I:ACILITY T, ESTINATION'STATE(IF R>AcaulR o' � <br /> r.. <br /> 1 <br /> i <br />