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`G tt afar, toaiZ a copy to : i} tr+(, .t_�Bair 4m, Sacralarmto, GA qu,124mau *tt"j .V dnvs�- <br />Please print or woe. (Form,desianed for usa nn Atha 11.9 n­.,r;rer i <br />CrN roan oruu-c2 tRev. 3-051 Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />- - - r-Orm Approved. UMB No. 2050-0035 <br />2. Pa <br />UNIFORM HAZARDOUS 1. Generator ID Numberge 1 of 3. Eme� ern (Response Phone 4. Manliest Tracking Number <br />-A <br />WASTE MANIFEST e 1 J K <br />C OOZ G M. !� v� i "011lC'"4^214-M 1005756939 <br />{J <br />5. Genera'toes Name and Mailing Address Generator's Site Address (if different than mailing address) <br />n 1 <br />14n -z Z,i1f <br />1 -s !t r ,5' <br />/((moi y 4I.J f+"v (� ` C--{/ + 6 r .7 t t o ) <br />tC, a,A( ( 1,4 1 7 1. l i L A. � <br />Generator's Phone:`-, <br />6. Trans iter 1 Company e U.S. EPA��413M <br />�111�i�1i3#�i�iil'!'#t`siAidfi{#'ii�iii il/EC�'1► <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Addr �s§ U.S. EPA ID Number <br />f1l- :lkfI r%e'4$bom San Jose, LLC <br />Www A, /� <br />101'1 ny(! sa Rd., San Jose, CA, 9s'i,_4,i CAD 310 <br />V-451' a <br />Facility's Phone: <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />O <br />�(_ <br />Z <br />2. <br />W <br />3. <br />4. <br />14. Specj p ndlip Ins dithn tallR t.�ii; 1 I �. <br />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, aged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small ghantity generator) is true. <br />GeneratoeslOfferoes Printed/Typed Name Signature Month Day Year <br />Z <br />16. International Shipments <br />1:1 Import to U.S. ❑Export from U.S. Port ofentry/exit <br />- <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed d Name Signature t Month Day Year <br />/ <br />ZQ <br />Transporter 2 Printed(fyped Name Signature` Month Day Year <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space QuantityI El Full Rejection <br />El Residue Partial Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1 . <br />2. <br />3. <br />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 />Printed/Typed Name Signature Month Day Year <br />CrN roan oruu-c2 tRev. 3-051 Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />