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Department of Toxic Substances Control <br />Sacramento, California <br />2. Page I Information in the shaded areas <br />is not required by Federal law. <br />of 4 I Egft <br />ist Document Number <br />rtor's ID <br />R <br />N <br />5. 'Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.[ <br />5tate;of California—Environment rotection Agency <br />„Rgrm A5 <br />pproved QMB No. 20 9 (Expires 9.30-99) <br />See,'.,Instructions on back ge 6. <br />Please prig type. Form resigned for use on elite (12-pitcf) <br />rifer. <br />$r <br />UNIFORM HAZARDOUS <br />-77 -Generator's USEPA 1D No <br />,4 <br />Manifest Document No. <br />, <br />WASTE MANIFEST <br /># - <br />L <br />6 ®-Y / P .3 <br />' <br />r <br />Com) ✓f ( f �� d I <br />F. Transporter's Phan �}/y �y j,.. <br />w <br />3. Generator'sName and Mallin/p Address <br />%/✓ 4f /"9r"Y <br />t- r <br />�X19A e,J .1--� <br />„1, <br />A. State Mani <br />Y)9. <br />Desi noted FacilityName and Site Address 10. US EPA ID Number <br />- & KLEEN JOSE) INC. <br />Dely /j�j/'N <br />}4�C.j, 1h9, <br />B. State Gene <br />(SAN <br />C A t? 0191419141 <br />Generator's Phone! ) �*� <br />ltZM <br />tY <br />5336 <br />Berryssa Road <br />Department of Toxic Substances Control <br />Sacramento, California <br />2. Page I Information in the shaded areas <br />is not required by Federal law. <br />of 4 I Egft <br />ist Document Number <br />rtor's ID <br />R <br />N <br />5. 'Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.[ <br />tp, t t/ <br />EVERGfw�f� ONMENTAL SERVICES <br />�t <br />D. Transporter's Phone <br />$r <br />CAC992413252 <br />+' <br />r- <br />'F <br />r ;Tra oit r 2 Company Name 8. US EPA ID Number <br />E. State, Transporter's ID [Reserye <br />A <br />-� <br />r <br />Com) ✓f ( f �� d I <br />F. Transporter's Phan �}/y �y j,.. <br />w <br />�QV' <br />�! <br />." <br />„1, <br />LVLT- r <br />Y)9. <br />Desi noted FacilityName and Site Address 10. US EPA ID Number <br />- & KLEEN JOSE) INC. <br />G. State Facility's ID <br />,Da <br />(SAN <br />C A t? 0191419141 <br />H. Facility's Phone <br />ltZM <br />tY <br />Berryssa Road <br />San Jose, CA 95133 ICIAID101519141914131110,.,. <br />aa <br />V <br />Wt,"' <br />11.,,US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/vol <br />C } <br />No. <br />Type <br />P <br />3 <br />� <br />.- <br />© <br />"' •� <br />bGsG�d G 1 141" W4/le C%61a%P:� <br />a; <br />.13 � <br />// <br />19,913 P <br />7q <br />c. <br />81ai <br />- a0 <br />,0 <br />. <br />EPA <br />.:R <br />Lu <br />d. <br />staff <br />u <br />Ely <br />a t *s+rtpbons for Materials Listed Above,m <br />K. Handling Codes for Wastes <br />Listed Above <br />AL <br />i5gd5peciol Handl Instructions and Additional Information <br />otacm,� ».. <br />LU <br />VOVNISFF/-�lnor R eX <br />gene <br />ar P Tel. ' cloths /—` >s'� �r3� Ili cif L.iing X -/ <br />a, <br />t— <br />16. GENERATOIFS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propershipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />`J IF I am a large quanti generator, I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical) <br />d g y <br />a practicable and that I ave selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and Future threat to human health <br />N and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />ovailable to me and that I can afford. <br />O <br />} Tped Nom q` o. Signatur Month Day Year <br />U`11 <br />: 0 `�. t .{ ,_(71Ic 171,-A'1(� t _ ,£ t. <' l �y r 1 e I d"" I d I al 01 <br />Printed/Typed Name Signature ^, f Month Day Year <br />nt9d/jyp@ci slam EigRaru o /Day: year' <br />s- I fA J <br />19:,Discreponcy Indication Space <br />y rPr <br />dr" ped Pjsme_ r SignatuyEi % Month Day Year <br />DO N WRITE BELOW THIS LINE. <br />V; Yellow: TSDF SENDS TI -11i COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC`8022A (1/99) (Generators ha <ubmit hazardous waste for transport out-of-state, <br />P111111CO compleird copy of this copy and send to DTSC within 30 days.) <br />EPA'. 8700-22' <br />