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ilk SHIP# 227611255 Please print or type. Form Approved, OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number ✓ _ . ,3 2. Page.41 of 3 . Ern Res se Rho pp 4, Manifest Tracking Number WASTE MANIFEST t: C� 9 ' t lu i 1 , OLIN14 W, ° 1 / k1006959732 SKS 5 . Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Mot or Guard ' Corparat ion MAN'1ECA CA 5337k-!R?000 Generators Phone: 6 . Tans o ny „ � .. r, U . S. EPA ID Number v �, . �f `� -r ; ' � s : .J� Iwi ZNC 7. Transporter 2 Company Name U .S. EPA ID Number CLEAN HARBORS ENVIRONMENTAL AL SVC Ii' CI 8. Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U .S. EPA ID Number 1021 BE PYESSA ROAD SAN JOSE , CA 95133 Facility's Phone: 9a 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit and Packing if an 13. Waste Codes 9 Grou HM P ( Y)) No. Type Quantity Wt.Nol. X 1 ' NA,`341077 SinZAR OLI3 WASTE3 SOLID , Na Di Sm -�'t r P 1 OO' : IJ S D001 0 , ( LEM, CHROMIUM ) , 91 PG III z 2 ' "ill�� " t Gt C t ( � ' 2I;Ct6.�S �r�t iaTl" SOL I D34 Li�1 P 352 ( hn� ) RBENfS CONTAMINATED WITH 01L. ) ; +I; 7 .. 3. rJ 4 14. Special Handling Instructions and Additional Information T8D k 8 T 79 1 r91 4 .19 71 M034003 3 C8B k ilit171 ° 244 Ff+iERGENCY S0 ._468c q. 1760b 41CH / SK / TF 4. tContract reta .1ned by gen rotor confers a ency author1 1 sy an initial -transnortpr° to o rld or substitute additional ti% aT soortars on � n � t� auo ^ l s behalfu 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 1 am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the 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. Gen aratorVOfferors Prmted/Typed Name Si nature'' r Month Day Year 16. International Shipmentsy F- ❑ Import to U .S. ❑ Export from . . Port of entry/exit:- z Transporter signature (for exports only): Date leaving U.S . : W 17. Transporter Acknowledgment of Receipt of Materials F .Tvr tis rier 1 Printedrryped Name `1 Signature Month Day Year W r y 0! ; 1 YY114 > �+; Z Tfanporter 2 Printed/Typed-Name Signature ""' Month Day Year F° 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity Type 1 ❑ ❑ Residue ❑ Partial Rejection Full Rejection y Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S . EPA ID Number J_ C� Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z 0 19. Hazardous Waste Report Management Method Codes (i.e . , codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2. 3, 4. 7 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPFl F} ..... ?o1;22� ( 2Ayl JZ- 7)Pre vviou )edlQ sfaLe h}o e�te 3039GENERATOR' S INITIAL COPY