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SSL SK T# l sID58es 4 I I Illi llll�I I III III I ISI I�I III <br /> ay,6,7-3 0 1' 4 7 6 4 2 4 8 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2056-0039 <br /> UNIFORM HAZARDOUS 1.Generate ID Number CAL0003513017 2 Page11 of 3.f2i <br /> r 4w—f"o 4.Manst Tracking Number <br /> WASTE MANIFEST 1/LS 1054764248 SKS <br /> 5.G rylor ame and MailingAdd rens Generators Site Address(if different than mailing address) <br /> ��1 everage San Joaquin <br /> 4547 Frontier Way <br /> Stockton CA 95215-9675 <br /> Generators Phone 209-948-9400 <br /> '9AF fgltL'&R SYSTEMS, INC. US EPA 0Nurrrber TXR000081205 <br /> 7,Transporter 2 Company Name <br /> 5.EPA ID Number <br /> 9.Designated Facility Name and Site Address E HARBORS SAN JOSE LLC U.S.EPA ID Numbor <br /> 1021 BERRYESSA ROAD <br /> SRN JOSE , CA 95133 <br /> 408-441-0962 CR0059494310 <br /> Faakys Phone: <br /> ga 9b.U S.DOT Description(ndudag Proper Shol ing Name,Hazard Class,ID Number, 1).Containers 11.T.W 12.U. <br /> HM and Packing Group(I any)) No. Type 13.Waste Codes <br /> y Quantity WI Not <br /> X 1 NA3077 HAZR DDU WR TE OLID N.O.S. D D007 181 <br /> o (BRAlkE SHAVINGS WITH �HROMIU�i), 9, P <br /> • � �i III <br /> 11, I� <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Sfa dal Handling Irsbuctfons and Additional Information T , <br /> 24 HR EMERGENCY #1-800-468-1760 (SAFETY—KLEEN) <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: hereby declare That Nrnent <br /> e nlents of this consignmare fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> narked and labeledlplararded,enc are in all respects in proper condition for Iransporl according to applicable intemalioral and nalional govemmental regulations.If export shil and I am the Primary <br /> Exporter,I certify:hat the contents of this consignment confom to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste ninimizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a smE#quantity gaharatdr),4 true. <br /> GeneratorsrOtferors Prinled7Typed Name Signature MoNh Day Year <br /> -s 16.Intamatloral Shipments <br /> zImport to U.S. ❑Export from U.S. Port of enlryle _ _- <br /> Transponer signature(for exports only): Date leaving U.S.. <br /> w 17.Transporle AD nowledgment of Receipl of Materials <br /> FC Transporter 1 Pnn edrTyped NaSignalure Month Day Year <br /> on Z—z- <br /> ZTransporter 2 t T Name Signabre <br /> r, Month Day Year <br /> F15 0- <br /> 18.Discrepancy r <br /> 18a.Discrepancy Indication Space r <br /> LJ Quan:ky ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Plwna: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> H <br /> Q <br /> Z <br /> N19.Harardaus Waste Report Management Method Codes r a,cedes for hazardous waste treatment,disposal,and r"Li systems) <br /> uj 1. I+y4 2. 3. 4. t <br /> 20.Designated Facility Omer or Operator Certification of receipt of hazardous mateni covered 9y the man as need in Item 18a <br /> Print yore eme Si n Year <br /> EPQJi -Wrouseditionsareobsolete. IGNATED FACILITY TO DESTINATION STATE F REfOUIR ) <br /> 4; <br /> a <br /> SFP 17 2015 <br /> tNVIRONMENY y <br />