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I <br /> PPW 811(2021 Form Aoroved. OMB No.2050-0039 <br />DNIF,0RH HAZARDOUS <br />WASTE MANIFEST <br />1 . Generator ID Number <br />CAR 000142562 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />(800) 424-9300 <br />4. Manifest Tracking Number <br />Oililtal itsioLe <br />Generator's Nome and Mailing Address Ganoratons Site Address( d fiereni Man mailing address) <br />Chevron Products Company Chevron 210997 1442 A Colony Drive <br />Po Box 6004 Ripon,CA 95366 <br />San Ramon, CA 94583 <br />rieineralnos Phone,: (877) 5494435 ATTN:Waste Tracking Desk i <br />Transporter 1 Company Name ....VS FPA ID Nurr.t.., <br />Clean Harbors Environmental Services, Inc. 1 MADO 39322250 <br />TranspOrter 2 Company Name U.S.EPA tD Number <br />I <br />5. Dee-oiled. Fac7lity Name and Site Address U.S EP ID Number <br />Clean Harbors San Jose LLC CAD05949 4 3 1 0 <br />1021 Berryessa Road <br />San Jose, CA 95133 <br />Fac; ity's Prione (468) 441-0962 J <br />9.3. Pb. Li.S. 001" Descriation (Including Proper Shipping Name. Hazard Class, ID Number, and 10. Containers 11. Total 12. Unit 13 ..''.',,,F.•.e c.:-.1..-?.5. <br />HM Packerig Gm .c if er,y:1) No, Type QuerlfitY Wt.Nol <br />NA3077. HAZARDOUS WASTE, SOLID. N.O.S.. (BENZENE), 9, PG III 0018 352 <br />x 6 r r);,.? /5c; <br />- 14.Special Handling Instructions and Additional Information WORK ORDERe 4997332 0 PROPRP PPR MUST <br />1.03938196 ERG#171 ')'J',0,4,1 BE WOR.N• <br />Contract retained by generator confers agency <br />on initial transeorterocLadd orsubstitute additional tfananorl onstenstato ottes of transoortelimoefficienize_senvereence. or safety authority <br />15 GLNERATiON'SiOFFEROR'S CERT FiCATIDN: nereby declare that the contents of tills consignment are rutty and accurateity described above by the proper <br />shipping name, and are classified. packaged. marked and labeled/placarded, and ire in all respects in proper condition for transport according to applicable international <br />anc national governmental regulations. If export shipment and I err the Primary ExipOrter. I certify that the contents of this consignment conform to the terms of the <br />attached EPA Acknowledgment of Consent. <br />Certify that the waste minimization statement identified in 40 CFR 26227(3) (III am a large quantity generator) or (b) (4 I arn a smaii 1.:i.,..I1ly generator) is true. <br />GatonsiOffercO ?anted/Typed .1ame e &gesture '...1,,ii r Day <br />Ara4,4 ".-- rivzcz e"-44.1:9 et 1 — <br />i /'.'1 , ., <br />le International Shipments . mport to U.S. II Export from U.S. Port of entry/exit: <br />Transporter Signature (for exports oruyi. Dale feaving U.S.. <br />17. Transporter Acknowledgement of Receipt of Materials Mont Day Year Signaltz....11?_ /.<47... Tram. iwrWitr 1 PrIntOfiglped Name <br />P i -e-ri cz 1 1 /2 1 1 „oith.kcie <br />Transporter 2 PrinterrTyped Name Signature Month Day Year <br />I I 1 I <br />18. Discreoancv <br />1Eta, Discrepancy Int:Seaton Spaoe IIII Ouantiy ii Type OResidue OPartial Reiection El ouri Reection <br />Manifest Reference Number <br />Alternate Feeney or Generator; U.S. EPA ID Number <br />Hacility'e Phone: I <br />Signature of Alternate Facility (or Generator). Month Day year <br />I I I <br />19. Hazardous Waste Report Mana_gernen <br />1. 14141 , <br />2. <br />Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling <br />lr tams 3. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the man feat except as noted in Item 18a <br />PrintediTyped Name Signature Mon th Day Year <br />I I I I <br />EPA Form 8700-22v (Rev. 3-05) Prevoius editions are obsolete.