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>= SK SHIP#. 22137777 <br /> I , <br /> Please print or Type.(Form desgned for use on elite(12-pitch)type nter.) Form Approved.OMB No.2050-00'x9 <br /> UNIFORM HAZARDOUS 1.Generator ID Number? " 2.Page l bf 3.Eme ency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST CAC 4�@25654 1 1—t3► 0-4E�8-1 `hk" SKS <br /> 5.Generate s Name and Mailing Address r` °' <br /> Generators Site Address(if different mar M011mg address) <br /> tHorida <br /> Ela <br /> L;rr:> 01:et} <br /> f t_.il#;3i CA 95840-7802 <br /> Generators Phone: X119--443--542"l <br /> 6.Trans rter 1 Compan Nama U�.EPA ID Number <br /> -it r" --t(:C EUN 4 YST..Er(S, NC. <br /> 7.Transporter 2 Company Name } Q a U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address <br /> (CLEAN H BOOS SAN.JCSE U.S.EPAID umbar <br /> 1021 BE�YESSA ROAD <br /> SAN j0S , CA 551.33 <br /> �IY�B'-ti�+1—✓3962 <br /> Facility's Phone: <br /> Its. 9b.U.S.DOT Description(including Proper Shipping Name,Hajard Class,ID Number, 10.Containers ti.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtNo!. <br /> cc! X .NA-312.'7% k a=+''ART QU8 .WASIE S ID, N.G.'S. DIY P T,.O 5 ''•oo"", t>008 <br /> [CHREMDOM, LEAD <br /> ca <br /> sC .: 2•a Mr tarn r I <br /> AND ettl <br /> 4. - <br /> i — <br /> 14.Special Handling Instructions and Additional Irrformaibn ` <br /> TSD'JSJ 71413663 LO-24049 C:u:G <br /> _j f <br /> i!F" S#'17 <br /> ! 2)E'RG#128- 1 � .i <br /> c 4 tart i':M6 GtNC't' #i--600-468-176 i (SK TF'I) <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above ny the p,eper shipping name,and are classified,packaged, <br /> marked and labeiedlpiacarded,and are in all respects m:proper co rfion fortransport according to applicable international and national govemm'rtal mgulat ons.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment'cvnfor m to tlge terms of the attached EPAAcknowledgment of Consent. <br /> I certify,that the waste minimization statement.identified in 40 CFR 62,270)(if I am,a large quantity,generator)at(b)(if I am a small quantity generator'is true. <br /> Generator'sl0tferor's Printed/Typed Name 1 : Signature i Month Day Year <br /> -• 16.International Shipments ; <br /> Z ❑Import 0 Export from U.S.- Pqd of entrylexit <br /> Transporter signature(for exports only): .L. -: <br /> r ; Date leaving U.S.: ... <br /> LU <br /> 17.TransporterAcknowledgment of Receipt of Materials , <br /> F rr 0gporter 1 Pdntedljyped Name t Signature/ <br /> O i 7 r Month Day Year <br /> IL <br /> ,.. <br /> 149 Transpodo Name n Signature .•^ <br /> Month r� or <br /> - � Day Year <br /> 18.Discrepancy t�- i <br /> 16x.Discrepancy Indication Space — �- <br /> ❑Quantify Q Type. Q Residue .. Q Partial Rejection ❑Full Rejection <br /> _ t Manifest Reference Number <br /> lr 'i 8b.Alternate Facility(or Generator) U.S.EDA.10 Number <br /> w Facility's Phone: <br /> w 8a Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> :z <br /> r� `.9.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> a 2. I' 3, 4. <br /> Rfi <br /> 20,Designated Facility Owner or Operator.Certificatian of receipt of tiara ous materials covered by the manifest t as notein Item 18a, <br /> Primedfkj�edirgme Srgnafu�d, <br /> �y . - Monti Day Year <br /> er <br /> EPAI=®rm-8T00=? (1ev�3-0a P�evrous-eds4onsar�obsolete. .. fT`fTC3 GENERATOR --- <br /> i <br />