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SEL CK SHIP## P'P7442600 I'�Ik�II I� II'I I �III�III�I'�II� <br /> 0 0 6 7 7 6 7 8 3 S K 3 <br /> Please print or type. Form Approved.OMB No.2050.0039 <br /> 1.Generator ID Number . 2.Pa a,l o 3. Tracking Number <br /> UNIFORM HAZARDOUS <br /> 'kl p 0 6776783 SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Itis e,. D Li Ft inc. <br /> ,8'0 Ril la Eie.-y <br /> TRRCY CA <br /> Generators Phone. <br /> 209-229-74140 <br /> 6.Tr&wnrteriY[,o—mpdn�tNaroe SYSTEMS I)'S US,EPA ID Number T0000 1L: <br /> 805 <br /> .L:05 <br /> 7.Transporter 2 ComppanyName U.S.EPA ID Number <br /> C1_FAN HARBORS ENVIRONMENTAL SVC INC.. MAD4339322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE. U.S.EPA ID Number <br /> 112.121 BERRYESSA ROAD <br /> SAN 705E , CA `•3`'�1;� <br /> 4418-441-0 c: CAD059494; 0 <br /> Facility's Phone: <br /> go 9b.US.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouanfity Wt.Nol. <br /> Q1 5 ."IA E <br /> K <br /> W 2 NON RCRA HA7ARDOLIS WASTE SOLIDS, � 8M 3+� F' 223c� (DEBRIS, PETROLEUM HYDROCARBON51 <br /> - nivin -- <br /> 4, <br /> 14.Special Handling Instructions and Additional InformationT-gD ^J 7 88�n 7,4i7 LI4P 78 i CCr.', <br /> 0 <br /> 24H EMERGENCY#I:800-468-1760-s€4''9K/TF-I--Cofltrac1 re+;a:ir+ed oY 5enerator confers a.pn-"y %s,iI y <br /> on initial transporter- to add or substitute additional trans�Drters On enera.tar's beha)f. <br /> 15. GENERATOR'SIOFFEROR'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 labeledfplacarded.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 EPAAcknowledgment of Consent, <br /> I certify that the waste minimization statement Identified In 40 CFR 26227(a)(if I am a large quantity,generator)or(b)(if I am a small quant) enerator)is true. <br /> Generator'slOferoes PrintecTlyped Name Sign ure Month Day Year <br /> at t� tq <br /> 16.Inte ational Shipments <br /> � ❑Import to U.S. Expos from U.S. Por of entrylexit. <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> K 17.Transporter Acknowledgment of Receipt of Materials <br /> w Signature Month Day Year <br /> OTransposer 1 PrntedlTyped Name� ^� g <br /> Z 2 Pante R ped Name Sig a Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> r 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone. <br /> � 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Repos Management Method Godes(i,e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q 1 2 3. . 4. <br /> Ll20.Designated Facility Own Aerator.Garth anon of sec t hazardous materials covered by the manifest except as acted i 8a Mo th !qa <br /> PnNedlTyped Name Signature <br /> EPA v -1 oµge ? r.-.tea,: DESIGNATED FACILITY TO EPA's e•MAyIPEST SYSTEM <br /> d>�1G:T F-af rvzze�vrr�� � <br />