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SK "3H1P# 2'3111219347 <br /> PleaseI print or type, Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 11)Number 2.Page I of 3.Emergency Response Phone 4 <br /> 7 <br /> Manifest Tracking Number <br /> WASTE MANIFEST n 0— r <br /> lu I , 140906 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> C <br /> .iLkFLQ i"'orporat ion <br /> 25?5' 9 Airport Way <br /> SIL91i <br /> Generator's Phone: :a-7",1-670-8053 <br /> 6,Transpuri I Company Name <br /> SYSTEMS Mr U.S.EPA ID Number T Y Ri <br /> 7.Transporter 2 Company Name U.S EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S EPA 10 Number <br /> Ill BERRYESSA ROAD <br /> Facility's Phone: SAN JOSE CA 9511-3 CAD059494310 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1 a.Containers <br /> HM and Packing Group{if any}) 11 Total 12.Unit <br /> No. Type Quantity Wt.Nol. 13.Waste Codes <br /> CRA HAZI1RDOUS WASTE 2-011-IDS, <br /> (API ;E. CONTAMINATED WITH OIL), -Na- <br /> Z 2. <br /> W <br /> 10 <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> T13D 5 S-j 82839730 9C24P-A2 <br /> EMF-Rf3ENCY#800-4E-6-17E,(i---CIt/SK/TFI-CDtktraCt retained by generator confers agili authoril y <br /> T'm initial tr,,insl2ii to art d or, "ubstit;.tm 'af3ditjE:;na1. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATIOW I hereby 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 iaheied/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 cei,14 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(i(if I am a small quantity generator)is true <br /> Generatoes/Offeror's PrintecifTyped Name Signature Month Day Year <br /> —j 16.International Shipments <br /> 1— 1:1 Import to ❑U.S. ElExport from U.S, Port of entrylexit: <br /> Z I Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> UJI <br /> 0 i Transport&I Print rryped Name <br /> cr % Signature r Month Day Year <br /> Transporter 2 F11ntedrryped Name Signature i Day Year <br /> 18,Discrepancy I I <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18bL Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> U, <br /> � Facility's i <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 05 19.Hazardous Waste Report Management Method Codes codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 1 2, <br /> 4.T <br /> 20.Designated Facility Owner or Operator:Cerlificatior.Df receipt of hazardous materials covered by the manifest except as noted in ftern 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev..12-17)"Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />