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F;K P# ?1513A440 00 <br /> IIIIIIIIII IIIIIIIIII I <br /> -� 0 0 4 d 9 9 7 7 0 0 1 8 5 K S <br /> Please print or type.(Form designed for use on elite(120")typevmter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.E Response Phone 4oaonil ss,r�kly yt O <br /> WASTE MANIFEST CAL0003FP017 1 1_-yt68-175x) 9 7 8 SKS <br /> 5 Generators Name and Me"AWrM Generators Site Address(a different than mailing address) <br /> Dbi Beverage San Joaquin <br /> 4547 Frontier Way <br /> Stockton CA 95215-9675 <br /> Gerleralors Prone: 310-356-2300 <br /> 6 T c 1 Company Nemo U.S.EPA ID Nrxnber TX R000081205 <br /> TY- LFFN SYSTEMS, INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE LLC U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE ('A95t.}3 <br /> 4a15-441-096;' CAGi1'_�9494_'. <br /> Fachl Is Phone: <br /> 9a. 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padding Group(dany)) No. Type Ouardity WIIVol. <br /> Be@ two <br /> —FrfF qrA <br /> Z z NONE NON RCRA HAZARDOUS WASTE SOLIDS, 752 <br /> 11^F OTI_ OND ABFORSFNTS), N/A I yD <br /> a <br /> 14.Special Handling Instructwns and Additional Inion anon TSD:SJ 65933738 DB 1283 CSG- <br /> 24 <br /> SL:24 HR EMERGENCY #1-800-468-1760 (SAFETY—KI_EFN) <br /> l4'✓ <br /> 1 S. GENERATORSKIFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and aoaue"described above by Bre proper shipping name,and are classified,packaged. <br /> marked and labetedlplacarded,and are in all respects in proper condilion 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 to Bre terms of the attached EPA Admowledgmem of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(BI am a small quantity generator)is true. <br /> Genera rsl0fferoes PrimedlTyped Name I Signature Month Day Year <br /> et) n a <br /> j 16.Intemabonak Shipments <br /> � Impart to U.S. Export ft.VS Pon of entry/exit <br /> Transporter signature(for exports only): Date leaving U S <br /> w 17.Transporter Acknowledgment of Receipt or Materials <br /> T 1 PnnW"yped Name Signa A Month Day Year <br /> Transporter 2 Pmtftlyped Name in <br /> Month Day Year <br /> 18.Discrepancy <br /> 1 1 Ba.Discrepancy Indication Space ❑ouanut ❑Type ❑Residue ❑Partial Refection LJ =ate ion <br /> Manifest Reference Number. <br /> F 181a.ABemale Facility(or Generatar) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone. <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Yeas <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> w 1 2 3, 4. <br /> 20.Designated Facility Owner a Operator:Certificabm of receipt 01 hazardous rn3tenals covered by the manifest except as noted in Item IBe <br /> Mrxrrth Day Year <br /> yped Name <br /> EPA Form 8700-22(Rev.3-05)previous edi sareobsolete. IJESIGNATED FACIL TO OtSTINATION STATE(IF REQUIRED) <br /> 9rAy r 2)7560294/920865 <br /> `F. <br /> SEP 17 201-3 <br /> ENVIRONMENTAL <br />