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Please orint or tvoe- (Form dasioned for use on elite 09.rvtrdtl t—ritor 1 <br />96*/16o/a36�7y2 <br />EPA Form 6700-22 (Rev. 3-05) Preftus edflfons are ooSakte. <br />—bESIGNATE D FAdl UTYXD ESTI NATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1 GeneratorlD Number <br />2P 1of <br />age <br />3. ErneNum•, <br />Emergency Response Phone <br />4. Manifest Tracking ber <br />WASTE MANIFEST <br />C A L 0 0 0 3 4 4 3 9 4 <br />1 <br />424 9300 a eNr� <br />015104018 JJ K <br />G grajpr U me anQVMailing Address Generator's Site Address (i( different tlun mailing address) <br />iOF <br />530 PORT STOCKTON ST <br />STOCKTON CA 95203 <br />Generators Phone 2 0 9 9 4 3- 8 3 8 7 <br />6. T iter 1 Com an Name U.S. EPA ID Number <br />F EMOL ENVIRONMENTAL SERVICES INC <br />C A R 0 0 0 1 7 1 0 1 7 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />CLEAN HARBORS ENVIRONMENTAL SERVICES INC M A D 0 3 9 3 2 2 2 5 0 <br />6. led Fegility me aaRs Address U.S. EPA ID Numoer <br />1021 BEFIRARRYESSA ROAD <br />SAN JOSE CA 95133 <br />Fadli 's Phone. 408 441-0962 C A D 0 5 9 4 9 4 3 1 0 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number. <br />10. Conlamem <br />11. Total <br />12 Unit <br />13Waste Codes <br />Ne. <br />Type <br />HMand <br />Packing Group (d axry)) <br />Ouantiry <br />WI:VoI. <br />. <br />x <br />1 RQ UN1760, WASTE CORROSIVE LIQUIDS, N.O.S., <br />141 D008 D002 <br />o <br />(RINSEWATER WITH LEAD), 8, II (13002) <br />OU\ <br />PTP <br />C'\ <br />w <br />z <br />4)" <br />c� <br />X <br />-1'41•+ <br />3 <br />,d Spec4 Handling Instructions and Additional Informetion 1)CH 1103008 / Rinsewater with Lead /Corrosive ER(3#171 2)('.H 1083925 / RIrlSewater ' <br />Lead ERG#171 <br />1 Y2"1-5- 4j" 1AU O t CIL46 006"149 HANDLERS TO BE 40HR TRAINED AND USE PPE. ER ConhacY # 205907 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Nis consignment are fully and accurately described above by to proper shipping name, and are classified, packaged. <br />marked ald labeled placarded. and are in alt respects in proper conduonl6r transport according to applicable intemabonal and natorul governmental regulations. If export shipment and I am the Primary <br />Exporter. certify that to contents of Nis consignment conform to Ne tens of to attached EPA Acknow"ment of Consent. <br />lore * Nat the waste mmemvstwn statement identified! m40 CFR 26227ia) (f 1 am a large quantry generator) or (b) (d I am a" tiry generator) is )tie. <br />Genmxdors101feroe Pmledlryped Signature Monty Day Year <br />2616 A.db t3I IL <br />J <br />F- <br />1 Iwemational 31wpirrieft <br />❑Importto .S. [I Export Portoten ,exd <br />= <br />_ <br />Transporter s"Iture (tr exports only). Date lea U.S.: <br />W <br />17. Transpnner Acknowledgment of Receipt of Materials <br />Transpncer t Pnnted.?yoed Name Signature Mont Day Year <br />M <br />Jl7s�AQ i� 0!0 13 IL <br />Z <br />Tracspoder 2P-ter_Typed NNcreno Signature Month Day Year <br />fX <br />/ <br />A J •`� �� <br />18 Discrepancy <br />18a. Discrepancy Indication Space ❑ ouanoly ❑ Type ❑ Rescue ❑ Partial Rejection ❑ Fu•i Resection <br />Manifest Reference Number <br />16b. Alternate Facility (or Generator) U.S. EPA ID Number <br />7 <br />U <br />Faddy, Phone. <br />W <br />16c. Sgnanne of Alternate Facaty tor Generator) Mont Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management fletriod Codes G -e.. codas for hazardous waste treatment, disposal. and recycling sysbms) <br />U.1 <br />o <br />17 U / <br />- e; ,rated Facility Omer Of Operator Certification of receipt of hazardous materials covered by to nw*W except as noted in Item 18a <br />1, kions Day Year <br />EPA Form 6700-22 (Rev. 3-05) Preftus edflfons are ooSakte. <br />—bESIGNATE D FAdl UTYXD ESTI NATION STATE (IF REQUIRED) <br />