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.L <br /> Please print or type. Form Approved. OMB No. 2050-003. 9 <br /> UNIFORM HAZARDOUS 1 , Generator ID Number „ �, r .� , � : moi, 2. Pageal of 3. me n R s o se Pho a 4. Manifest Trackin Number <br /> ( 1,., V► , r1krl.� is � st ' � ,j � . , CJ � 7 � 5 SKS <br /> WASTE MANIFEST <br /> 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> 71 't `3 L F�if� fw+ Y� r. t < <br /> Generator's Phone: P019 - �P •1 ,'3 911 �� <br /> 6. Tr�, er,yljo r n1 a4r, am_ g �,tr �+ ' i .,, U.S. EPA ID Number mnmp <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> C 4I HARBORS ENV SVC "�:ENG4 <br /> 8. Designated Facility Name and Site Address r+ r U.S; EPA1D' Number <br /> OSI l ERRYr., i ROAD <br /> 814N JOSE CA T <br /> t• l� f6'h ! f sC . ., i ial} fr 'F` r4t s4f1 <br /> Facility's Phone: <br /> 9a. 9b. U.S. DOT Description, (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol, 13. Waste Codes <br /> 1 . Hf&''Zf4! RI1XJ8 laAME, `3R.11. ID s flf P <br /> o ( OIL I" 11,.. ERS ) I <br /> �.r <br /> W <br /> z 2. <br /> 0 <br /> 3. <br /> lad <br /> 4, ENVIRONMENTAL <br /> 14. Special Handling Instructions and Additional Information yl r�,,c # ;h8 7 CE2105909 C 01, Q ff <br /> rektai. ried by paerator corifr:rs aRelicy at-tthfav% i, : ty <br /> kt11 1ftitr �d I aouransiPartter ;. c, c` Hd cor subsrt6.1t to a4�ditj. onaI tra"1i`ta00r IteY' S 0 r gener'Afurg s, beha '1 '` „ <br /> 15. GENERATOR'S/OFFEROR'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, . <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 certity 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 quantity generator) is true. <br /> Generators/Offeroes Printed/Typed Name Signature Monthaaaaaaaaa Day Year <br /> ij <br /> 16. International Shipments Export from U.S. Port of en /exit: <br /> El import to U.S. ❑ p try <br /> ? Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name F Signature Month Day Year <br /> Z Transporter 2 Qdnted/Typed Name Signature " ? Month Day _ Year <br /> t, <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space Quantity ❑ Type yp El Residue El Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U .S. EPA ID Number <br /> J <br /> U <br /> tai Facility's Phone(' <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> J9Aiazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> UX <br /> p 1 • 2. 3. 4. <br /> I20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdnted/Typed Name Signature Month Day Year <br /> Form 8700-22 (Rev. 12-17� Previous' editions are obsolete. GENERATOR' S INITIAL COPY <br /> i } s<i`} 1 &E1103/ I5 i 7I <br /> -f <br />