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Please prim or type.(Form designed for use on little 12- itch 6JR 170254$499-002 SC PPW 1/4/2017 9 ( p )typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator lD Number 2 Page l,pt 3 Emergendy RespprPMne t4. (test Tracki NumherWASTE MANIFEST C A R O O O O 4 9 9 4 2 2 ($OOj 4$3371$ �,p g g g 6 FLEMailingAddress a ) 23755 W Kertleman Ln.. 2395 W Ketlteman lrt Lodi.CA 95242 2355 95242 Generator's Phone:(8001597-222$ ATTNSMre Mana¢er ranspoderl ompany me U.S.EPAIDNinnber Clean Harbors Emironmenlal Service,In¢ M A 130 O 3 93 2 2 2 5 0 7.Transporter 2Company Name U4,EPA IO Number 8.Designate C Facility Name and Site Address U.S.EPA ID WnNur,Y Clean Harttors San lase LLC 1021 Bef Vessa Road CAD 0 5 9 4 9 4 310 San Jose.CA 95133 �.' Faalily's Phone' (40$1441-0962 ga 9b.U.S.DOT Description(including Proper Skipping Name,Hazard Class,ID Number, 10.ConLainere it.Total 72,Unit 1 and Packi Grou i HIMHIMn6 PCdam Y)) No, Type Quantity '� 13.Waste Codes o x EXCEEDING i L CAPACITY),2-1 0 01 C.F 00072 P DOOi D035 331 �a 2 UrII WASTE FLAMMABLE LIQUIDS N.OS.,(ALCOHOL, U002 vfw 1=1 X ACETONEI,3.PG 11 001 D F 0 0 013 p D005 6007 '331 3 UN3139,WXMOXIDMNG LIQUID. NAS, UM 001 DF 00023 P 0001 141 X HYPOCHLORITE.POTASSIUM PERMANflANATEI.5.1.PG If ° UN3266,WASTE CORROSIVE LIQUID.BASIC.INOR ANIC, D002 122 X N-OS.,(SODIUM HYDROXIDE,POTASSIUM HY Ey,$,pG 001 OF 0 0 0 0 6 p 11 14 Special Handl instructors set Additional information 1.Tar—AOI 126 1€65 is 2.TAR-FLAM—L EPZ#126 1XS' 3.TAR—£CX—L "ERG0140 1X5 4.TAR-SASE—L ERC4154 1XS 15- GENERATOR'SIOFFERDR'S CERTIFICATION: Ihereby declaraftne mMents of this cceeielmet am fully and accurately dnsaNw3 ebm by a,aproper shipping team.and are desndtktlpedaged, marked and Labeledlpiacankd,and are in an respects in pmpermrxf(aan lortransyort according m applicable imemaronal and national govemmetitid niolations.If expert shipment and 1 em the Exporter,I certify Red ftre contents of this consignment cordorm to the III of the stationed EPAAck owledgment of Consent. I cedily that the waste minimization statement identified in a0 CFR 282:27(a)(III am a Large tprenti Y geaarala)or p1{N I III III is We. Stu 7� 1 ane tins NALFOF iT 05 26 117 .;� i&International Shipments z EJ hand to U.S. ❑Export from U.S.. Ped of e Transporter signature for exports onl : per. S,e rL 17.Transporter AcknWedgment of Resompt of Meameals cY Iransfewar1 PdnlndRyped Name um ear a CHRiS RORIN.gnN 05 26 17 Transporter 2 Pdnted4yped Name Monte ear t— ¢. IS Discrepancy 18a.Ciscrepancy Indication Space ❑ Qg 7 ❑TYPe ❑Residue ❑Paniai Rejeclbn ,.' ❑FWI Rejection 18b,Alternate Fancily(or German ManifastReferonce Number U.S.EPA ID Number ZS ux Fach 's Phone: - d wlee Nmalumotntemale Facihiy(or GeneraoQ Month Y Da Year i 4' a sw 19.Hazardous Waste Repan Management Method!Codes(i.e.,cordes for hazardwrs wash aeetmem,disposal,and recyft system) !n 1 2 Hi4j. 3. 141 ( 20.Designated Facility Owner or Operator.Certification of receipt of hoz fd=matenais covered by the manifest except as noted in sem 1 j PnndName With L 1I^l � jDay — EF'AFot1#e01i'B BflbaetttiaraDYrayr ei¢Nfairs rind will aeoeptttwW egeneEVNiR koLITYTO DESTINATION STATE(IF REQUIRED)