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w `W <br /> Store of Califarnio—Envirenmental Protection Agency See Instructions on back of page fCSn04E, Depormtemn of Toxic Substances Conical <br /> Form Approved OMB No.2050-00391Evpirm 9-30-991 5ac.am•nro,Califar.,io <br /> Please print or typo. Fwm dnigmd for uw an elite(12pihhJ ypewris,r. <br /> . Generator's US EPA ID No. Manifest Decument No. mhnnatian in the+hod•d areas <br /> UNIFORM HAZARDOUS I is not required 6y Fed"Icw <br /> WASTE MANIFEST ` �1 5 � 1 err <br /> 3. Generator's Name and Moiling Address A, State Manifsat Dacumenr Number <br /> Trtevor P erty $^^^ 23639956. <br /> 519 NorthhPatlan Avenue a. Stats G.n.etd s ID <br /> o SE-kion CA 95215 <br /> "It 4.Generalo/s Phane I I <br /> (V <br /> h. US EPA ID NumTrans <br /> Number C. Stone ra <br /> 5. Transporter 1 Companysporhls ID[■.serval.] <br /> m - D. Transporte(s Phone <br /> 8 Clean Harbans EDY Services incE. Sa.TansP«e✓.ID{g�.l <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number <br /> F:TransporWs Nho e <br /> QD 1.S71J 10. US EPA ID NumMr L. Sbs,FociOy's ID <br /> 9. Deaignaled Fo<iliy Name and SIIe Address <br /> cya Clean Harbors San Jose LLC 10 14 19 1 A 13 11 10 <br /> e?z 1021 l3orTyessa Road ". FecWit/s Plan. . <br /> MO San Jose CA 95133 <br /> o- 0 408 451-0000 <br /> f <br /> J 12. Containers 13. Total le. Unit <br /> Cy)6 11. US DOT Description(including Proper 5hippirrg Nome,Hazard Cl.,,and ID Number) No. T Ouantl Wt/Vol I.Wass,Number <br /> nFzstate ,31 <br /> NON HAZARDOUS,NON D.O.T.REGULATED,N/A.NONE <br /> ot16� � � ENs/tDlfier <br /> 3 O v T i <br /> sten <br /> o b' <br /> N <br /> m E EPA/Osfr <br /> A I Slav <br /> w O FS `s - EPA/t016er <br /> R Stas, <br /> W d. OFF I <br /> 8A/011s,r <br /> W <br /> V <br /> W K. Hatsdlina Codes for Walls Listed A6. <br /> 1.Additesnal Dow' ems for M°Miol+Listesf Above <br /> a , b. <br /> d <br /> w <br /> a d. <br /> s <br /> 4 <br /> z1 special Handling Instruction,and Additional lnformaeon EMERGENCY PHONES(8�)403 3718 <br /> Wear Proper PPE v*wn h2rtCI W p waste 11 a:CH66662 <br /> z <br /> w <br /> x <br /> 16. GENERATOR'S CEanF1CATION: 1 hereby declare that the contents of ilii:coroig em are folly and acmrately dsuribd abort by proper shipp,ng name oral oro dosat. poc <br /> Q marked,and k6dod,and are in all r..pecb io proper condition for transport by highway according a applicabb ins,rnaFond—a natiorwl government regalations. <br /> If I ora o huge quantiy genarafar,I certify Cot I have a progwm in ploce to reduce the volume and toxicity of waste generated so IM degree I have desermined so ba economically <br /> i5- practicobb and Nal I have selected the ractica61e method o Ireatmem,storage,cur dip I currently ovoilabk to me which minimi...the present and future threat to human heoBh <br /> s' and the environment OR,if I am a small quantity gen•raleq I have made a go ohh f to minimize my wash gererotian and select the best wash management method that n <br /> W oval.6le to me and tiwt 1 con afford. <br /> O Printed/Typed tame - Sign / Monlhl IT J 0 1( <br /> rl 1 11 f;r !� r/ <br /> W i 17. Trans r 1 Ackrawled emmt of Receipt of Materials <br /> 17 Month Dot Year <br /> ¢ ; Pei /TYped t"IO • Si aaN <br /> a <br /> W s � LL Y11 <br /> F <br /> W p 1 . Trans iter 2 Acknowled ement o4 KIC1.111 of Moledok Month pay Year <br /> O Printed/Typed Nome Signature <br /> N r <br /> R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. FociS Owner or O an.tar Certification of raaei t of ho.ordous materials aov b This manifest exec t os n In Ite Man Day Year <br /> T Primed/Typed Name Sign \" '. ( / Q <br /> Y 0 _ `e 1 1 1 <br /> DO NOT WRITE BELOW THIS LINE. <br /> White: T5DF SENDS THIS COPY TO DTSC WITHIN 30 DAYS, <br /> DTSC 6022A II/99) To, p.0. Box 3000, Sacrcunenro,CA 95812 <br /> EPA 8700-22 <br />