Laserfiche WebLink
. ( V ter.) Form Approved.OMB No.2050-0039 <br /> 2.Page 1 of 3., m R s Fhq 4. ayni s aykinNNu be r� SKS 0@406 s9@ 1 fT -Ur i r e Li • i. �°, Q C7 a�I�a7 <br /> IU Generators Site Address(it different than mailing address) <br /> jOX 3i@8E V <br /> CA 95215-7956 <br /> (IQ.StEPA ID Number TXR@0@Ia8120F <br /> �S;:i IISIPAIDNImber <br /> RBORS SAN JOSE LLC U.S.EPA ID Number <br /> RYESSA ROAD <br /> CA 95133 <br /> • CAD0594943121 <br /> Ird Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM <br /> and Packing Group(ffany)) No. Type Quantity Wt.Nol. 13.Waste Cotles <br /> NONE NON RCRA HAZARDOUS WASTE SOLIDS, D14 D 35 ' <br /> 0 (USED OIL AND ABSORBENTS), NIAIL <br /> z 2. <br /> w <br /> C7 <br /> 3. <br /> AUG 0 2015 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 67671670 D121596 CSG- <br /> 24 <br /> SG-r..4 HR EMERGENCY #1-800-468--1.750 (SAFETY—KLEEN) I �(),- 0.3 �(`y <br /> LICENSEDSK AUTH RIZED TO RETAIN T 4 AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform W the terms of the attached EPA Acknowledgment of Consent. <br /> I ceNly that the waste minimization staitenbint identified Ing 9FR 262.27(a)(ff I am a large quantiq generator)or(b)(if I am a small quantlty generator)is We. <br /> GeneratoessDfferors PrintedlT Name i Niguel ry Month Day Year <br /> sillr <br /> 16.1 t ationa hipments <br /> ❑ <br /> F Impto U.S.ort ❑upont from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> K <br /> TranspQWr1 Pnnted[TyDed.Name Signature Month Day Year <br /> O - <br /> ,a V . . ,... Z;l <br /> QTransporter 2 Printed(Typed Name Zignal Month Day Year <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityType Residue <br /> yp Peril Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Fall(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Deal Facility Owner or Operator.CeNfication of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Prrinted/Typed Name Signature Month Day Year <br /> EPAFo 8g700-2y(Rev.3-05 Previouseditionsare b='i'te. - DESIGNATED FACILITY TO GENERATOR <br /> 1)7�367tA4 99987 <br />