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5�t. lili al-{T f'•f� c':l�1 )c',�llt;,l� �•'• ,:�i <br /> Please print or type.(Foran designed for use on elite(12-pitch).typev✓riter.). Form Awroved.OMB No.2050-0039 <br /> 1.Generator ID Number 2Page e C 1ry <br /> UNIFORM HAZARDOUS g )1 of 3. me �� Riq�oCe P. , anlfesthack(n mber.. <br /> WASTE MANIFEST 4"� u . SKS <br /> 5.Ge erafors N e and Ma In ddr�,�s a (� <br /> d,G]it vend �Irg9 1'INi.rt Generators Site Address((f efferent thenmailing address) <br /> 'W"11 Navy b., <br /> Generators Phone: <br /> iJ{{f'h.•�'i;; -'fit"r 7a <br /> B.Tran���tef-� U.S.EPA ID Number. <br /> fXF lelema.I;Rosi , <br /> 7.Transporter 2 Company Name U.S.EPA ID Number. <br /> B.DesignftegFadfity Name.and Site Address . CLEAN HfIRBORS SON JOSE U,S.EPA IDNumber <br /> .r BAN ,?CJBE � CA 95133 <br /> .C4�f10494x� <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Descdptlon(Including Proper Shipping Name,Hazard Class,ID Number, 10.Oonlie -rs 11.Tobe 12.Unit <br /> HM and PackingGroup(Ifeny)) 11 Waste Codes ' <br /> No. Type, Q!Mntky, WtNol, <br /> 1. fV€1i1�[C Nt7f5L Ru'i t'± fif1 .A1tllCls1: 4 i;.IT, '5.1.317T's Y E,}(=t P. 3152 <br /> 1Vt77tx� t .L7'fi 1'Il.)t. i�llra Yr 0 , <br /> 2 <br /> CP <br /> S <br /> �l <br /> 4. <br /> 14:S'ectal Haridimg InsWFljpn's and Additilord 17or—mdon 7.` Rr, ;r, <br /> i'4 ITY,:Ti�) ��rl�.��:'g�>�t...4F�f�"-116131. 1'-SK r� TF1 <br /> AI3'C'"A5 rr�'W:'y NT—F-r)R„ BY SEEN`TO RETAIN )..T�•f-:.NS-►,) SUB ENiRRICRR <br /> 16.. GENERATOR'S/OFFgRgfS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are elessltied,packaged,, <br /> .`fnarkdd and lab'dlediplacarded,and aze In all reso%ls Ip pre ar ca clition for transport according to applicable International and national governmental regulations.If export shipment and I em the Primary <br /> r`fkponor;I certify that the coolants df thls'oensldnment 661e6 to the terms of the attached EPAAckndwledgmentof Coneeot. l <br /> = <br /> ...I certify that the vreste minimizallon statement Identified In 40 CFR 2B2.27(a)(if I am a large quantity generator)or(b)(if]em a small quantity generator)Is true. <br /> GaneratoealOfiaroes Printedffyped Name " Signature nlh Day"' Year' <br /> •.r. .t::: 4.. 3" •r� I:r, '� r'. „ ' _ r"' .•''-. <br /> ..r 16;Intemalkonal Shipmentsti. <br /> �t <br /> _ ....,. <br /> r � r::L.. .. ..� : i, <br /> ❑Import b US. El Export frern U.S. Pod. <br /> od of ehtryle:dt: '"• <br /> Transporter nature fare ortsonl r' , <br /> P 9 t xP Y) -.....,. ..-... .. Dale leaving U.S. <br /> 12 <br /> Trans�drtefereedNarneecelptofMateriele <br /> p rr Pidnted/f.YP r 5 r r: Signature Month Day Year <br /> .Transp•e 2 Rrlptedgypeci Na. :, .�:.1 r; F f.Sfglla teMon <br /> .18a.DilawapaneyIndication Space: El <br /> n <br /> r• p type°. Rwdue ❑Partial Rejection .. ❑Ful Re cad <br /> �! Manifest Reference r <br /> Numbe <br /> JA <br /> ' UA EPAID <br /> -- — - <br /> ua FactRY6 Phone: <br /> w 1 Bc:SlgnaM cf-Allemate Fedilty(or0ewdor <br /> tE <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,andrecycling systems). <br /> 2. <br /> 20.Designated Facility Owner or Operator.Certification of recelpt of hazardous materials covered by the manifest except as rioted In Item 18a <br /> Pdntedrfyped Name Signature MwonthY Year <br /> EP✓�I1orfl�T�fl ,2.i�Reyvr ;0}�,�P_��vlaus edltionsare obsolete. GENERATOR'S INITIAL COPY <br />