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51 SK SH P# ;w•2_,2E�2034 NI�IIII III I�INI��IIN <br /> 0071a1977SK8 <br /> Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emerye�y ResOonse Phone 4.Manifest Tracking Number �� <br /> WASTE MANIFEST CAL1I1003586 1 1 ti LR-4h9 1761 <br /> 5.Generator's Name and Mailing Address Generator's Ste Address(if different than mailing address) <br /> D L. G 1_i ft Tnt.a <br /> 3,820 ?hondia Way <br /> TRACY CA 9.,:304-16+38 <br /> Generator's Phone: -09-2 G-744$ <br /> 6.Transporter f Company Name U.S.EPAID Number <br /> BHFETY-Ki_EEN SYSTEMS INC TX1:000081 05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAR HARBORS ENV SVC INC. MAD039, 225G <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN S115F. U.S.EPAID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 951 31-1CAD059494110 <br /> 408-441-1396' <br /> Facilites Phone, <br /> ge 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if ani No. Type Quantity Wt.Nol. <br /> rr 1' NC RCRA HAZARDOUS WASTE SOLIDS rim C' 223 <br /> (FEBRIS, PETROLEUM HYDROCARBONS <br /> i 150 <br /> UJ <br /> Z z. NCN—R€.RA HAZARDOUS WASTE, SOLID DM P 21'23 <br /> (CIL FILTERS) <br /> 1 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD SJ 805R4543 DD02783 <br /> 24H EtIERSENCY#800-468-1760-I H:SKtTFT-Cantractretai>1er3 by generAtar ronft}>,s a envy authori y <br /> _ , - <br /> Arirl <br /> 15. GENERATOR'S/OFFEROR'S CE 71FICATION: hereby declare that the contents of this consignment are(ally and accurately descdhed above by the proper shipping name,and are classified,packaged, <br /> marked and IabeledlplaceNed,and are in all respects in proper condition for transport according to applicable international and national govemmental 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 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 quantity generator)is true. <br /> 011e is Printedlryped Name Signature Month Day Year - <br /> 16,International Shipments ❑ - <br /> ImpodtoU.S. ❑ExportfromU.S. Portofentrylexih <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> of 17.Transporter Acknowledgment of Receipt of Materials <br /> Lu <br /> � s r 1 PdntedRyp �etl Na � ignature Month Day Year <br /> O <br /> 2r ro-2 Frinted✓\ype arae n ..3 Day Y r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> J <br /> V <br /> ua Facility's Phone: <br /> W 1821.Signature of1temate F; K (or Generator) Month Day Year <br /> 6 ' <br /> 2 <br /> N19.Hazardous Waste RVpol Maqgainent Method Codes(i.e.,coVs III hqardmilis waste treatment,disposal,and recycling systems) <br /> G1 2. 3. 4. <br /> 20.Designated Facility 0 herr rator:Cirlificatiln of FFjbgofh&ardous materials covered by the mardfest exceptas noted - M <br /> Printed—Na <br /> Signature -- <br /> EPA Form 8700.22(Rev.12- revious editicV e. DESIGNATED FACILITY TO EPA's a MAN EST SY T M <br /> 7 1tAt_05F_34/150»5 6 <br /> ?0��.;J1567;' <br />