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. . SI{ SHIM# 230525229 <br /> II 1 <br /> Please print or type 0 6 Farm Approved OMB No 050-0039 <br /> 1 Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Track, Number <br /> UNIFORM HAZARDOUS CAL�0Q1358631 0 072 5291 a KS <br /> WASTE MANIFEST ! L7 �7 <br /> Generator s Name and Mailing Address Generator's Site Address lif different than mailkng address) <br /> 3K0 Rhonda Way <br /> T P i CA 95304-1608 <br /> Generator's Phone: '09-229-7440 <br /> 6 Tr�Tcc�aany Name U.S.EPA ID Number <br /> '?—TLP FEN SYSTEMS INC TX I70000B 120'- <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MADOd393 22`" <br /> 8 Designated Facility Name and Site Address CLEAN HARBORS SAN NOSE U.S.EPA ID Number <br /> 11021 BERRYESSA ROAD <br /> SAN J09E , CA 95133 <br /> FaciliVs Phone408-441-0961 ` CAD059494310 <br /> - <br /> ga 9b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10 Canty Hers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. <br /> of 1. NON RCRA HAZARDOUS WASTE SOLIDS <br /> o S, N ) <br /> W <br /> � <br /> z ICRP HAZARDOUS WASTE, SOLID <br /> JiL FILTERS;" <br /> 4 <br /> 14 Special Handling Instructions and Additional Information TSD,9 T 82229537 DD02781-''. <br /> a�U3�_ <br /> 4H EMERGENCY#800-468-1760–CH/GK/TFI–Contract retained by generatom.tanfil a envy 4packLai <br /> thor�i y <br /> t r�na" `- - n - r r- o p �� -1 <br /> 15 GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment artfully and accurately described above by the proper shipping name,and are classified, <br /> marked and labelediplacarded,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 Aentified in 46 CFR 262.27(a)(if I am a large quantity generator)or(b}(if I am a small quantity generator)is true. <br /> E iCif or's Priniedrfyped Name Signature <br /> Month Day Year <br /> 16-International Shipments <br /> r— 17 Import to U.S. 17Ex rt from U S. Pod of ent pa rylexil: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> CC 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> a der 1 Prinledllyp"me ] ignatu Month Day Year <br /> Mill v� I � ! I to <br /> Z TilPrirrleclffypad Name ure Month Day Year <br /> a <br /> 8.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fuli Refection <br /> Manifest Reference Number <br /> 18h-Alternate Facility(or Generator) U.S,EPA ID Number <br /> U <br /> r4i Facility's Phone <br /> W 18c.Signature of Alternate FaCliiry(or Generator) Month Day Year <br /> H <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste Ireatment,disposal,and recycling systems) <br /> w 1, 2 � � 3. 4. <br /> O <br /> 20 Designated Facai 0 er Aerator:Certifica n r eip f hazardous materials covered by the manifest except a a Sa <br /> Printed/Typed Name Signature Mo h <br /> EPA Fain 8700-22(Re . Pr vious editions ete. DESIGNATED FACILITY TO EPA's e-mANiFESI SYSrEM <br />