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5$L SK SHIP# X25978988 <br /> Please print or type.(Form desgnad for use on elite12- itch i <br /> ( D )bPewd(ec) Form ApProved.OMB No.20540039 <br /> UNIFORM HAZARDOUS 1,GenemlorlDNumber 2Pageld 3. R nseP i 4.Manif st m?,Numb5 y <br /> WASTE MANIFEST CAL0E6043i865 1 1 1 @�--4 8-1760 �118 3 71,4 J FLE <br /> 5, enerator's Name and Wing Address Generators SlteAddress(if different than maling address) <br /> Kia Country <br /> 1,915 N Main Rt <br /> NANTECA CA 95i3E5--3243 <br /> Generators Phone: 999-999-9999 <br /> rare��uu��eer CompanyName U.S.EPA ID Number <br /> SWTY-KLEN SYSTEMS INC TXRO@C081205 <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> CLEAN HARBORS ENVIRONMEWAL SVC INC. 101AD039322250 <br /> 8.Designated Faci ty Name and Site Address CLEAN HARBORS 5AN .7OSE U.S.EPA 10 N=Nunber <br /> 11021 BERRY958A ROAD <br /> SAN JOSE , CA 15133 <br /> @ <br /> 4@'�-441"•@9S2 CAD�9'i'iy31 <br /> Failliys Phone: <br /> go, 9b.U.S.DOT Oescription(inUWing Proper Shipping Name,Hazard Clan,ID Number, 10.Containers fi.Total 12 Unit <br /> 13,Wesie Codes <br /> HM end Packing Grcup Of any)) No. Type Ouanaty WNMI. <br /> NONE NON RCRA HAZARDOUS WASTE_ SOLIDS, 1) I p 3 c <br /> (ABSbRAENT AND OIL), N/A ` (� <br /> i 2. <br /> w <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handing Instructions andAddOanei Information TED.53 771144663 K118372 CSG, <br /> R4H EP1ERtiENCY1#80J0^469-.i760-CH/9K/T1=I-Contract retained by 9-n- ;.k confer a ency aifihori y <br /> n ini .i. tv,A son :Pr to cid r slhet`.tat:P . I itir. ;,1 rte S nr+. rte n rent , .nr, s e1nl <br /> 15. GENERATOR'SrOFFEROR'S CERTIFICATION: I healrydedare that the contents of Ws consignment are fully and accurately dearnbed above by the proper shipping name,and are ciassifed,packaged, <br /> marked and abeledfplacarded,and are In all respects in paper condtion for transport according to applicable ntematiaal and national governmental regulations.N export shim entand I am Ina Primary <br /> Egwrter,I certify mat the tenants of this consignment conform a the arms of the attached EPAAckmwledgment of Consent. <br /> I ceNfy that the wase minlmlzatitn statement aertned in 40 CFR 26227(a)Of I am a large quantity generator.cf(b)Of I am a small quantity geneater)is sue. <br /> CxuieraWWOffarrors Pdntedfiyped Name ogMonth Year <br /> 16.International Ship ants - <br /> ❑ImporttoU.S. ❑Exporlfrom U.S. Paddenlryhxib <br /> Transporter sl nature fa exports eel : am leave U.S- <br /> W 17,TransporterAdwidedgnenl of Receipt fMt <br /> oeceiptoaerlals <br /> �, Transporter 1 PrmudTyped Name rte 4 Y) ear <br /> CIL <br /> z Transporter Protaffiyped NameSig <br /> rmare Month Day YM <br /> 4. 18.Discapancy <br /> 18a.Discrepancy Indication Spars ❑ Quantity ❑Type ❑Resld;e ❑Padml Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Ganeralor) U.S.FPAID Number <br /> J <br /> U <br /> uQ. Fag Fhone: <br /> w180.Signature DIAllame1eF9dlity(erGeneaar) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Memad Codes(i.e.,codes for hazardous waste aeaanent disposal,and racycring systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Dealer or Operator..CeNikation of"0 of hazardous materials covered by the manifest except as noted In Item 18a <br /> Pddedffyped Name Signature _ Monrh Oay Year <br /> EPA Form 8700-22 fRev.3415) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 1)73572-22./944502 <br />