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SK SHIP# '&2126831442 <br /> Please print or type. �Nwnbe, Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number Page of 3. 4.Manifest Tracking Number <br /> UNIFORM HAZAR�DOUS CAD9 I I <br /> WASTE:MANIFEST I aa"87444 SKS---- <br /> .5,Generator's Name and Mailing Address GA (i i ere I r&l&�l s) <br /> Sh <br /> Cal-Trans to 10- 30110 CWS <br /> 1603 6 B ':3�, RE <br /> ST OCKTON CA 95-206-24,v, <br /> Generator's Phone.. Z09-948-7813 kinv I <br /> U.S.EPA ID Number TX Flef-00@8 1 <br /> SYSTEMS iNC <br /> 7.Transporter 2 Company Name <br /> CLEAN HARBORS ENVIRONMENTAL SV;�' T�JC. ENV y�—V� IEN`j FtIIIIIiE bftilnBer MAD039322250 <br /> nP PAVI TMV N-T' <br /> 8.Designated Facility Name and Site Address C-i-EAN HARBORS SAN JL-123c" U.S.EPA ID Number <br /> 102-1 BERRYESSA ROAD <br /> SAN4 <br /> JOSE 95131;� <br /> Facility's Phone: 408-441-0962 CAD059494310 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> X l NA3077. HAZARDOU'S wpui-E SOLID ?4. 0. s� D <br /> DOZE D007 <br /> 0 (CADMIUM, CHROMIUM), �, PG I I I <br /> Z 2. <br /> LIJ N RCRA HAZARDOUS WOSTE SICLADS, (DTP D M P 181 <br /> FILTER/TRAP CLEANER WASTE) <br /> 3. <br /> 4, <br /> 777 <br /> :11;i�,7::72 CA 4 7 5 14 CSG <br /> 4 H Em'E <br /> retained by generator confers a envy authoril <br /> nirdl t ±ns, <br /> nar -r to hahaf, <br /> 1 <br /> 5. GENERA -fOFFEROR'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 /> III Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA.cknowledgment of Consent. <br /> I certify that the waste minimization statement'Identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatcr'siofferors PrintedTypedName Signature Month Day Year <br /> q <br /> 16,Intematl6nat.Si'lipments <br /> LJ Import to U.S. ❑Export from f entrylexit: <br /> Transporter signature(for exports only,: Date leaving U.S.: <br /> -7ransporter Acknowledgment of Receipt of Materials <br /> ILI <br /> I,-- Transporter I Printed/Typed Name Signature Month Day Year <br /> 0 <br /> Transporter 2�Inted/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space El Quantity El Type ❑Residue 0Pirtial Rejection EJ Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Fadifty's Phone: <br /> U0 77c Signature of Xternae Fac <br /> tility for Generator' Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(Le., for hazardous treatment,disposal,and recycling systems) <br /> U) <br /> 3r <br /> LU 4. <br /> 20 Desigrated Faalitv Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 5r <br /> intedIfTyped Name Signature Month Day Year <br /> I I I <br /> EPA Form 8700-92`R-v 12-17)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />