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L T &C.. 0.1246..-16-Z1 <br />Please print or Noe. (Form desioned for use on elite 02-oitch) tvnewriter.l D127i44i$ SC PPW 1/20/2010 Form Anoroved. OMR Nn 2(1.5D -(1D39 <br />EPA Form 8/U0 -'ll (Rev. 3lJb) Hrevious editions are obsolete. 1.1iCJK,a1NIA 1 CU rA%,IL11 T 1 V UC, I IIYA I K.0 arm 1 r kir f7CWU1 rw) <br />clean Marbvrs has the appropriate permits for x10686.1220* waste the generator is shipping <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 000024319 MWI <br />WASTE MANIFEST <br />CALO 0285075 <br />1 <br />800 4833718 <br />5. Generator's Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />Tele*ne Risi.Inc. <br />32727 Corrol Hollow Road <br />32727 Corral Hollow Road P.O. Bos 359 <br />Trap, CA 95378 <br />Trap CA 95378 <br />' <br />Generators Phone: (925145"700 <br />ATTR• <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Clean Harbors Environmental Services Inc <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Clean Harbors San lose LLC <br />1021 Berrressa Road CAD 0 5 9 4 9 4 310 <br />San Jose. CA 95133 <br />Facility's Phone: (40M "ll 4962 <br />93. <br />9b. U.S. DOT Descnpton (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12 Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (it any)) <br />Quantity <br />WtNol. <br />i- <br />1' UNi993. WASTE FLAMMABLE LIOUIDS.OS.. HACETONE. <br />QQ 900 <br />DO <br />L FOO <br />ISOPROPYL ALCOHOLA 3. pc 11 , c�boi� <br />A <br />o <br />bm. <br />Z <br />2. <br />w <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />1 _CH335932 ` -fSS ERIG#128 <br />Wsz� D <br />15. GENERATOR' OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmerif are fully and accurately described above by the proper shipp ng name, and are classified, packaged, <br />marked and labeled placarded, and are in all respects in proper condition for transport according to appl cable inlemational and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I ce" that the contents of this consignment conform to the tents of the attached EPA Acknowledgment of Consent. <br />1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (A I am a large quantity generator) or (b) (ill am a small quantity generator) s <br />t Offeror's PrintedlTyped Na ign re Month Djay/ Yeokar <br />/J <br />&-- <br />jX6. International Shipments <br />Import to L.S. Export fro U.S. Port of entrylexit: <br />M <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Mat <br />W <br />Trans iter 1 Printedffyped Name Signa Month Day Year <br />0 <br />a <br />2r a <br />Z <br />Q <br />Transporter 2 Printed(Typed Name 6ignatuire Month Day Year <br />t' <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Qu ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL <br />' <br />Facility's Phone: <br />W <br />18c. Signature of Aftemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />2. <br />3. <br />4. <br />Hi41 <br />20. Designated Facility Owner or Operator. Certificatign of receipt of hazardous materials covered by the manifest eftptas noted in Item 18a <br />PrintedlT ed Namer�' �, I Sig Month Day /Year <br />�Q'f "� r QV�-� � 0- � In I !O <br />EPA Form 8/U0 -'ll (Rev. 3lJb) Hrevious editions are obsolete. 1.1iCJK,a1NIA 1 CU rA%,IL11 T 1 V UC, I IIYA I K.0 arm 1 r kir f7CWU1 rw) <br />clean Marbvrs has the appropriate permits for x10686.1220* waste the generator is shipping <br />