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1131K SHIP# 2 1162 15 se print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS fir}tilo!�u');� ."s'; i 1 -'}�I4t�-'!crF;•'1 �y ,�j � J�(] S�(e WASTE MANIFEST 3 4 9l Iia+ 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Li:3ca3 P;,.717-10 S ppt'd5. Lodt _ CA 9_.Z2.r 0---t 802 RECD J U L 17 2015 Generator's Phone: 6.Transporter 11 Company Name U.S.EPA ID Number St�FE} !J`Ii:...f.,6_I�( :..n)7 S�w EMS, iNCo f i{ K!tS�IG�i`y lIC,^;u'• 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address ) r;){ F1f�r� l,RS g1r r�.ri�l}� _ LI_iv U.S.EPA ID Number 1021 BERRYE:SSA ��L)AD yy SAN JOSE 1.:��' ."i,,�j•-_ - Facility's Phone: L 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit and Packing if an 13.Waste Codes HM 9 Grou P( Y)) No. Type Quantity Wt.;Vol. � 1 ; I:a� ? [?�i�:i"1�txti,J�i �?�STC", :illt.ZD, �V,i�. � ;�':r: -� E, �y -,_•- 3. tli7 CIr_�= 1iA w Z 2. w C7 3'. I 4. 14.Special Handling Instructions and Additional Information +-S n S G y5-55,tj-0 -^T c� t� KERS E;HE.h'.tR_i `-: .9r1 r-f(i-'HIJ RS e.�- �?' 1;�( { r� il.-�i-.r-' ,�t.,��:*r� i�{,T f.St�.r�. `•i ��-i �i -_=5r-,1:<.. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)41 am a small quantfty,generator)is true. Generatoet/9fferoes Printed/Typed Name Signature �/ f Month Day Year .-r 16.International Shipments / H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials � Transporter 1 Printed/Typed Name Signature Month Day Year O - j... CL / QTransporter 2 Phnted/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J c.> LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z u519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedlfyped Name Signature Month Day Year EPA Form.8I00-22(Rey..3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY