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Please print or type.(Form designed for use on elite(12-pitch, -,writer.) 7J9665804 SC PPW 1—,—1/2013 <br /> 1.Generator ID Num er Form Approved.OMB No.2050-0039 <br /> UNIFORM HAiARDOUS 2 Page 1 of 3.Emergency Response Phone 7007582474 <br /> anifest Tracking Number <br /> WASTE MANIFEST, GAL00 013863 1 (800)4833718 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Stockton USD-Edlson HS <br /> 1944 N.El Pinal Drive <br /> Stockton,CA 95205 1425 South Center St <br /> Generators Phone: Stad( an.CA 953206 <br /> 6.Transporter 1 Company Name <br /> . <br /> Clean Harbors Environmental Services Inc U.SEPA ID Number <br /> 7.Transporter 2 Company Name MAD039322250 <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> Clean Harbors San Jose LLC MAY 0 7 2014 U.S.EPA ID Number <br /> 1021 Berryessa Road CAD 0 5 9 4 9 4 3 1 0 <br /> Sart Jose,Ca 85133 ENVIRONMENTAL <br /> Facility's Phone: (40814.4.1-09 2 <br /> ga. 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1 NON-RCRA HAZARDOUS WASTE,SOLID,(BISPHENOL A 352 <br /> POLYCARBONATE) Q, ®F 3:50 <br /> LLJ2. PIAN-RSA lbr� R�E'�Srx/L)Ch/Sp�(c L� /� <br /> Poe Y�1VA70 0/ Dm ?M) A z <br /> 3. <br /> 4. <br /> 14.Special Wandling Instructions and Ad 'tional Informati <br /> 1.CH790341 �rSs FW ! Is-pP <br /> �.4+7QaS�(1 !X 3MF/A! / SSD H <br /> ? 96 e,L58o <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hdreby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respec In proper condition for transport according to applicable Intema6onal and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignmen conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that the waste minimization statement identifi in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)('d I am a small quantity generator)is true. <br /> Generators//offerorrs Printed/Typed Namergnature on ay Year <br /> 4 <br /> 16.International Shipments <br /> Z 1:1Import to U.S. ❑Export from U.S. Port of enfry/exit <br /> Trans iter si aturefore its and Date leaving U.S.: <br /> w 17.TranspotterAolmowledgment Of Receipt of Materials <br /> Transporter 1 Print ) igna re en ay Year <br /> CL <br /> QTransporter 2 Printed Typed Name Signature Month Day Year- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ---❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> a <br /> rf- Facili s Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1 <br /> Hi4i 2. 3' 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsol te. l DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> ^111--u>riawre/.>�•l.s >nwrowri a4.w. �1�fwe>w.l will s�nwwf f{..u>efa f6a 6sww�>ewr i<<Liwwiws <br />