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r.t SK SHIP# 22:0693168- Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emertgency Reponse Phone 4.Manifest Tracking Number WASTE MANIFEST CAD:9'pl19E;�E,8 .1 l_6�j�_4 6_).76 1005728117 SKS 5.G_enierator's Name and Mailing Address Generator's Site Address(if different than mailing address) aJ?-E_ilJ`t}} n D 0 dgyp uto Cener Cir Generator's Phone: 441-000-3000 6.TLS r 1Com,pant ,,me t� U.S.EPA ID Number I : s I S' STEMS, INCl, T.�R;�t�0081205 7.Transporter 2 Company Name U.S.EPA ID Number C-,tp CA In foA ) aa 8 Designated Facility Name and Site Address - ` U.S.EPA ID Number --_- _.s:l rAN �-'�k'I�i`I-ii4q _-. - 1021 zERRYES;SA ROAD SAN JOSE CA 9,,5133 40,6-441-t�.�6 ' r �-.-G Facility's Phone: t-�:.��`t�r`349Efi,'1 1,71 9�j 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HU and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. Icl=66 !BASrTEr� I'ETRCJLELI€ DISTILLATES, 4 DM D001 D008 D018 O i�s Se ^� o�F ..:i {""E`r TI 2 1 W Z 2. W C7 3. 4. 14.Special Handling Instructions and Additional Information , ,-,-,r _- T SD:SJ 71.88 �6 ST371 3 9 C�Sa 1)E RG#128" E4- HR LMOGENCY #1-600--466-1760 (SK i' TEI) AJTH AS "AGENT-FOR" BY CEI! TO RETAIN LICENSED S1JB CARRIERS A5 NECESSARY ARY 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, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I=that waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. aPrin d Name not ` ✓� '`� Month lay Ye� 16.International Shipments V 11 (9 F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: LU 17. -ransporter Acknowledgment of Receipt of Materials 0T asp iter 1 Printed/T Name Signatu Month Day Year a C cc e 11 a Transp Prin d/Typed Name--, Signature Month Day Year t- W,\ 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U W Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) � 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt#hazardous materials covered by the manifest except as noted in Item 18a��yped�NameP J /CSignaturenth Day Year � EPAorr,87D� RP�v.. 05}�PGeujous a tions are obsolete ✓ NATE _' INATI®N S7rE(IF ECIiIRED}