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G; 1 S11) u, IIIP11 � ' ,= it ] N 11111! 111 Illlll# IN111111N <br /> Please print or type. 0 0 7 1 Form Apprroove6d. SOMB lot 2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator ID NumNr ry ` . Pane 1 0l 3 Ema�gency Resparaa Fhaia MrrnHeu Tnckl p umber <br /> 96 SKS <br /> WASTE MANIFEST rAn � f3r = f 1 + t / e 1 f31'tk 71 (: f - 17fk <br /> 5. GeneraSor's Name and Mailing Address Generator's Sile Address td different than maitirg address) <br /> Nr.trra Trcl1 I PIr (l [h r.' t " 1 rJn Of 1l11gaf) <br /> 175a Mariposa RDa ' <br /> STOC114rON CA 9 9 . <br /> Generators Phone: 2099 08313 7 ,31; ,5 <br /> 6. Transporter t Company Namer U.S EPA ID Number T X Rk�000H 1 r k7 �r <br /> , nFETY - KL. rEN .SYSTEMS INC <br /> 7. Trarsponer 2 Company Name U.S. EPA ID Number <br /> 0 , EAN HARBORS ENV SVC IN ( . tdAi? 41393 ? � c ` 1Z1 <br /> 8. Designated Facaity Name and Site Address C 1 FAN HARBORS ARAGONITF ) t I C' US EPA IDNumNr <br /> 11600 NORTH APTIS, ROAD <br /> ARACIONI TE [ IT 1k4k+ '' 9 <br /> Faciiitys Pnone <br /> 9a 9b U 5 OOT Desaipdon (including Proper Shpp'eg Name, Hazard Class ID Number, 10, CD(1tamers 11 Total 12, Unit <br /> 15, Waste Codes <br /> HM and Paclung Group Of any)) No. Type Quantity WINI.o <br /> NON-- RCRA HAZARDOUS WASTE , SOLID , I� GI �' 35' ' <br /> ( F' AI �JT BOOTH FILTER ) <br /> Z 2 <br /> w <br /> c� <br /> 3 <br /> 4 <br /> ` 1 : Speaal Har,dlrg IrsUud au and Add conal Inforrrabon c <br /> TSD ® AG a01 �3F13 0 C E MLI 17758 CSG : <br /> I q <br /> 24H EMERGCi ICY # 800 . 4683 17r) Ot- CH / SK / TFI --Contract retained by ge iprhttirNconrerc) e9chor° i ' y <br /> + + <br /> 15 GENERATOR'S10PFEROR'S CERTIFICATION : I hereby declare that the contents of this wns�nment are fully and accurately described abate by the proper sh'.pprg new, and are classified , packaged, <br /> rnartced and labeiedlpiacarded, and we in all rospeds in proper cot tot uanspon accc4dux3 to applicable inlerroli*nal and nalicAal governmental regulations. If export shipment and I am the Primary <br /> Exporter, 1 certify that the contents of this consigmmnt conform to the terms of dre attached EPAAckrkWe4gmenl of msent, <br /> I cetily that the waste mai r;zaLen statement k]enh5erl in ; e CFR 262. 27(a) (d I am a large gdani:ty genera nr) m (b ;li am a sma!i quantity generates) is U e . <br /> Genera nfsf fierots PrinlediTyped Name Signature Month Day Year <br /> hawA 3a <br /> �j 16 International5lipments f 1 <br /> f_, , Import to U.S. tJ Export Iran U S Port of en'uylexat <br /> ? Transponer sgnalure ( for exports ordy): Date leaving U S <br /> W 17. Transporter AckmmAlerlgment of Recepf of Materials <br /> Transp(1to 1 PittititedrI)tTle 4me SignalerMonth Day Year <br /> CL W4 C ® <br /> Transporter Pante /Typed Name S:gna'It Ib Day Yea Year <br /> t5. Disuepar�y . <br /> 163OvaaUty T 1ve L _._1Resiaue Partial RetecJnn Full Rzie <br /> ct:or <br /> Manifest Reference Number <br /> I8a. Xternate Face%!y ( w Gerwralor) US EPA ID Number <br /> J_ <br /> U. Faatdy's Phone <br /> W 18c. Signature of Alternate Faaty (or Generales) blanch Day Yeat <br /> d <br /> z <br /> 19 . Hazardous Waste Report Management Method Codes (i e , codes fa hazardous waste treatment, disposal, and recyclirg systems) <br /> I ' 1 M 1 r^ 2 a. a <br /> l 20 0esgna;ed ` <br /> Facility weer or Operator Certficat cin of receipt of nazardous materials covered try the /tamest except as noted in I m t6a <br /> Pant y� }--y- , � 51g u i\t Vy i. Oa <br /> EPA Form 8700.22 (Rev 12. 17) Previous edilions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />