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Please print met 3CK toccurraqpmcPs;r .OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest TracOng Number <br /> WASTE MANIFEST 014563593 F L E <br /> 5.Generators Name and Mallin rent than mailing address) <br /> Oak Harbor Freight Lines,Inc <br /> 30iS Loomis Rd SAME <br /> G8Mfi%WD4A- 95205 <br /> 6.Transporter 1 Ea"��7-7 340 U.S.EPA ID Number <br /> 7. U.PEMPA160 9:3 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors San Jose LLC CAD 0 5 9 4 9 4 31 0 <br /> 1021 Be"vessa Road <br /> FEWMae.CA 95133 <br /> ga 9b.U.S.DOT Dcnp#MMRX4K Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unft 13.Waste Codes <br /> HM and Packing Group(ft any)) No. Type quantity Wt./Vol. <br /> 1. <br /> d NON-RCRA HAZARDOUS WASTE.SOLIDS,(EMPTY DRUMS) <br /> z 2. <br /> w <br /> 3. <br /> 4, <br /> 14.Spedal Handling Instructions and Additional Information <br /> 1.CH2 o 24471 <br /> l VSs'" <br /> l W"tt'Rrow <br /> marked and labeled*carded,and are in all respects in proper condition for transport according to applicable international and national govemawtal regulations.If export shipment and I am the Primary <br /> Exporter,I a:rtify that the contents of this consignment oonfonn to the terms of the attached EPAAcuowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is true. <br /> Generators/Offer&s PnnUA7yped NameSignature Mo�n+t-h- Daly Year <br /> L -A"w /�/ ' '/, '�S' <br /> 7 I <br /> t6.lntemational prrhents <br /> ❑Import to U.S. Fort from U.S. Port of enbylex t <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> M 17.Transporter Acknowledgment of Receipt at Materials <br /> tETransporter 1 Printed/T Name Signature Mtxdh Day Year <br /> d <br /> Z Transporter 2 NnWypad Name Signature Month Day Year <br /> l-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number- <br /> 1 Ob. <br /> umber:18b.Affemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U< Facility s Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> D 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1' 2. 3. 4, <br /> H14i <br /> 20.Designated Facility Owner or 0 tor. rtificabon of receipt azardous materials covered by the manifestAwyt as noted in ttem 18a <br /> Pri N <br /> r <br /> EPA Form 8700-22 Rev. 4-17) revious editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFE SYSTEM <br /> r^lpan Ha as tee zooms rlate nems for and wttl accent ttie waste the generator Is st wMa. VWQ1112AA-1 7QRA7Q6nA7 plan+ <br />