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State of Californio—Environmental Protection Agency ` <br /> Farm Approved OMB No.2050-0039{Expires 9.30-991 See Instructions on back of page 877048 Department of Toxic Substances Control <br /> a Please print or type. Form designed for use on elite f12-pitch)typewriter. 1 Sacramento,CoWomia <br /> 1. Generator's US EPA ID No. Manifest Document too. Information in the shaded areas <br /> r UNIFORM HAZARDOUS is not rega>red 6y Federal law. f <br /> WASTE MANIFEST 5 (p72114PA <br /> of <br /> 3. Generator's Name and Moiling Address SAM <br /> R. State Manifest Document Number <br /> 7Fsevorl� erty I23639956 <br /> 61S Nortfi Fratton Avenuef <br /> a Sto0ton. CA 95215 # B. State Generotar's ID <br /> W) 4. Generator's Phone I ] t <br /> n _ <br /> (V 5. Tramparier 1 Company 6_ US EPA ID Number C. State Transporters MIReserrnd.] <br /> a? t <br /> D. Transpprhrs Phone,_ <br /> C) Clean Harbors Erw Services in <br /> ro 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporters ID fResis .] - <br /> (�� � F:Transpnrtelrs Phone 1 <br /> L�IJ 9. Designated Facility Name and Site Address 10. US EPA ID Number G. StoM'Facihly'i_ID ` <br /> Cna Clean Harbors San Jose LLC ' ', 111 <br /> IIF <br /> CDZ� 1021 Herryessa Road H. Facility's Phone' 1 <br /> San Jose GA 95133 5 (4081451-MM 1 <br /> (Y 1I2_ Contoinars 13. Tot11. US DOT Description{including Proper Shipping Nome,Hazard Class,and ID Number] ity 1 4. Unit <br /> No. T Quanlnti Wr/Vol f. Waste Number <br /> NON HAZARDOUS,NON D.O.T.REGULATED,NIA,NONE slate ! <br /> EPA/Other <br /> 3 G Val r lIN in N <br /> N E 6. State <br /> o N <br /> ca E f EPA/Other <br /> v R 1 <br /> C44 A c <br /> State <br /> o T ' <br /> QFS <br /> `s F EPA/Other ] <br /> R {� y <br /> Lu d' OFF E State <br /> V I I <br /> w <br /> rn J. Additional Descriptions for Materials listed Above i K. Handling Codes for Wass■s Listed Abve <br /> o <br /> p b. <br /> 11a.(L) 1 <br /> Z o, 1 <br /> rn <br /> d <br /> Q I( <br /> Z 15. Special Handling Instructions and Additional Information <br /> EMERGENCY PHONE*(800)483-3718 <br /> Wear Proper PPE when handling waste i 1 a:CH66662 � r <br /> Z <br /> w <br /> zi 16. GENERATOR'S CERTIFICATION: I here6y declare that the contents of this consignment are fully and accurately described above 6y proper shipp ng name and are classified,packed. <br /> Vmarked,and lo6aled,and are in all respects in proper condition for transport by highway according to opplica6le international and natiossal govarnment regulations. i <br /> J If I am a large quantiy generator,l certify Ihat 1 have a pregrem in place to reduce the volume and toxicity of waste generated to the degree I have determined ro be economicollr <br /> practicable and Ihot I hove selected the proctica6le method of treatment,storage,or lisp I currently avdilo6le la me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,I have mode a ga aith to minimize;my waste generation and select the best waste management method that is <br /> Oavailable to me and tlsat I can afford. } <br /> y Printed/Typed Name Sign Month Day Year <br /> 1Z �t tear rN r 1 l e r f 11 D Y <br /> w 1 17. Transporter 1 Acknowfed emeni of Receipt of Materials <br /> A Pri /Typed Pia a Si nolo Month Day Year <br /> w + <br /> P <br /> LL 6 ; . Trans tier 2 Acknowled ement of Ric i r of Moteriols Iltr <br /> TPrinted/Typed Nome Signature i Month Day Year <br /> w E <br /> n R <br /> V19. Discrepancy Indication Space <br /> Z A <br /> C y <br /> I <br /> 20. FacilityOwner or Operator Certification of receipt of hazardous materials cov d by this munifast except ds n in he 19. <br /> T Printed/Typed Name Sign e Mant6• �Day� or <br /> ' <br /> DO NOT WRITE BELOW THISF LINE. <br /> p White: TSDF SENDS TH15 COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(1/991 p t <br /> EPA 8700-22 To: P.O. Box 3000. Sacromenfo, CA 95812 <br /> lk <br /> I <br /> + + F L <br />