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-n(- SK SHIP# 230472691 11111111111111111111111111111111111 <br /> Please print or type. as 72751953 KForm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Paget of 3. se P 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000081643 1 s' �-1 0 SKS <br /> 5 Generaloes Name and Mailing Address Generators Site Address(if different than mailing address! SKS <br /> a7 <br /> Ladd= Mai-ilia <br /> 4911 Buckley Cove Way Patricia Bonnifield <br /> 9TOCVTON CA 95219-2-0105 <br /> Generators Phone: 20 9-477-9521 <br /> 6Tr1 U S EPA ID Number <br /> - � SYS i EMS INC T X PI?10008112*0 <br /> 7 Transporter 2 Company Name US EPA ID Number <br /> ':I FAN HARBORS ENV SVC INC. MAD03932'225P.1 <br /> 8 Designated Facility Name and Site Addressa U.S EPA ID Number <br /> CLEAN HARBORS AN J[SF <br /> 1021 BERRYESSA ROAD I <br /> SAN JOSE , C'n 95133 <br /> 408-441-0962 CAD059494310 <br /> Facility's Phone: <br /> 9a 9b.U.S DOT Description(including Proper Shipping Name.Hazard Class,10 Number, 10.Containers11 Total 12 Unit 13 Waste Codes <br /> HM and Padang Group(if any)) No Type Quantity WI/Vol <br /> t_�" NON RCRA�HAZ DOUS WASTE l_IDUIDS ''" (,,1�jU <br /> O i�1� ri Fl-.F' , <br /> Q <br /> � I <br /> w <br /> LU 2 <br /> to <br /> 3 <br /> 4. <br /> 14 Special Handling Instructions and Additional Information TSD:SJ 8P17,_',850 LA28534^^,, <br /> C4H EMERGENCY#bPOO-4F8-1760-CH/SK/TFI--COntr.3Ct retained by gen,:­atov ncy authori y <br /> on initial r„-t f 9 s r , bpha <br /> 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. <br /> marked and labeledlplacarded,and are in al!respects in proper condition for transport according to applicable international and national governmental regulations.N export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mmimizaWn statement identified ip 40 CFR 26227(a)(if I am a large quantity Waeratoqkr(b)(if I am a small quantity generator)is true <br /> ene rs,Offerors ted/Typed Name Sgn Month Day Year <br /> _j International ShipmentsLj <br /> ❑Import to U.S. ❑Export from U S Port of entrylexiC __ <br /> Transporter signature(for exports only): Date leaving U S <br /> a 17 Transporter Acknowledgment of Receipt of Materials <br /> Trans iter 1 Pn ted"Typed Name Signature Month Day Year <br /> a Z2 rJ <br /> Z Transporter 2 PrinledTyped Name rn Zte Month Day Year <br /> 9 r i Cil LY Zc) <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) US EPA ID Number <br /> J <br /> U <br /> L Facility's Phone. <br /> w 18c.Signature of Attemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19 Hazardous Waste Reppri Vapgepent Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> coo 1 2. 3 4. <br /> 4 - <br /> 1�� <br /> ity Oper tor.Certifi tion of% o azardous materials covered by the manifest except as a <br /> 4edili <br /> ISAKAe� Signature M Year <br /> EPA Form 8700-22(Rev re los ato DESIGNATED FACILITY TO EPA's a MANIF T SYSTEM <br /> 1 )84F.'07_°- -- <br />