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Please print or type. ?,;fHS31g5 L!")—S J o 0 7 1FormApprooved.OMBNo.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 3. me an Res onsa one 4.Manifest Tracking Nual <br /> WASTE MANIFEST -AI_000358631 1—-@--4 A-1761.'0 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) SKS <br /> D & D 1_1ift Inc. <br /> -82,0 Rhonda Way <br /> rwlry CA 95304-1608 <br /> Generators Phone: "09-229-7440 <br /> 6.Trans ner 1 Com any Name U.S.EPA ID Number <br /> SfETV-LEEN SYSTEMS INC 7xR000181 05 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> €_FPN HARBORS ENV SVC INC. MAD0393 2251 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> Facility's Phone: <br /> 08-441-0962 CAD059494310 <br /> gs 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> i <br /> 1. NON RCRA HAZARDOUS WASTE SOLIDS, /A,). DM P 223 <br /> or (DEBRIS; PETROLEUM HYDROCGRBONS) <br /> z' NON--RCRR HAZARDOUS WASTE, SOLID LSM �( P ��3 <br /> C7 'nTi_ FILTERS) 41 140 /r <br /> I <br /> 3. T <br /> I <br /> 4 <br /> i <br /> I <br /> 1 <br /> 14.Special Handling Instructors and Additional Information TSDCSJ 805V;4543 DDI02783 <br /> 24H EMFRSENCV#801-469-1760-CHISKITFI-Contra^t retain e 17y generatnr cantrars a envy a hnri y <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, I <br /> marked and Iabeledlplacarded,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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)If I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> GeneratoeslOfferor's PrintedlTyped Name Signature Month Day Year I <br /> ,,kan ofil, 1.0 6Ua�� S f <br /> Jft.International Shipments <br /> r ❑Import to U.S. ❑Export Irom U.S. Port of entry/exit: <br /> ? Transporter signature for exports only): Dateleav'gU.S.: } <br /> W 17.Transporter Acknowledgment of Receipt of Materials fl 11K ; <br /> �i Transporter 1 PdnteU/fy ed me Signature Month Day Year { <br /> CL © t3 <br /> U) Transporter dnteel Name Signature onth Day Year <br /> / 3 / 4 <br /> 16,Discrepancy <br /> 18a,Discrepancy Indication Space ❑Quantily ❑Type ❑Residue Partl Rejection Full Re <br /> ecibn <br /> Manifest Reference Number: } <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> WFacility's Phone: <br /> LL, 18c.Signature ofAltemate Facility(or Generator) Month Day Year I <br /> z ' <br /> LU19.Hazardous Waste Report Management Method Codes(i-e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Ope or:Certification of receipt of materials covared by the manifest except as ed in Nem 1 <br /> PrintedlTyped Na Signature - - Mordh y Year <br /> b <br /> EPA Form 8700.22(Rev.12-17LPreviouseditions are obsolete. DE ATE CILITYTOEPA'se-MANI S STEM <br /> I)R0@.5834/150F53� 2)7612003/15 77 <br /> A <br />