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WSC 1906256699-003 SC PPW 12/9/2008 Forth Approved.OMB No,2050.0039 <br /> Please print or type. 2.page i of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> 1.Generator ID Number 1 014 2 4 9 2 2 5 F LE <br /> UNIFORM H I ARQOUS f$00`4B3-S71B <br /> WASTE MANIFEST C A L 0 O 0 2 6 S 7 9 4 Generator s Site Address(if different itlan mailing address} <br /> 5. tGE)Ci` OMMOGIES SAME <br /> 2001 Wagner Ave <br /> Stockton.CA 95215 <br /> Generators Phone: (925149"385 U.S.EPA t1)Number <br /> B.Transporter 1 Company Name M A D0 3 5 O <br /> Clean Harbors EnvironmentalServices,Inc. u.s.EPAID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address <br /> Clean H arbors San lose LLC GADO 5 9 4 9 4 31 O <br /> 1021 Berri Road <br /> San 1ose,CA 95133 <br /> Facility's Phone: 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) <br /> 1.NON-RCRA HAZARDOUS WASTE,SOLIDS.(SULFURIC ACID, �� <br /> 181 <br /> or SODIUM HYDROXIDE) <br /> W <br /> 3. <br /> 4. <br /> 1iSpe�da1an i- 94H38 <br /> nsctionsand Additional Information <br /> �4I11f3Ct���131¢t],�Y�72ff2f3t4t C¢tlfef5 3a� I . <br /> UltrI6111— otl Milli+l irdAr1r A1-1AI irJ di i! Ul.btiljbllltiL!' dULiE 4Vi1a3i tt�ilb 1iIlCib UIF Cn%fd�llk f;UCk1d1��Uf �LrbKb Ur�IE� shi lour€nalme�erd areLutdassrflad,packaged, <br /> 15. GENERATOR'S10FFEROR'SCERTIFICATION: Thereby dedarethat the contents of this consignment are fatty and acalratel described above by the props pP n9 <br /> marked and labeledlptacarded,and are in all respects in proper condition for transport according fo applicable e�f tionaland national governmental regulations.If export shipmem and k am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the berms ofdthe atta attached Euentity enrator orb if I am a small quantity generator)is true. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(5)( r9 q tY generator) ( )( Month Day Year <br /> Signature Q Z� <br /> Generatorsl0fferors PrintedTfyped Name / <br /> 16.fntemational Shipments ❑Exp0rI from U.S. Part of entrylexit: <br /> ❑Import to U.S. Date leaving U.S.: <br /> Transporter signature(for exports only}: <br /> tau 17.Tran sportorAcknowledgment of Receipt of Materials Mortth Day Year <br /> /Transporter <br /> 1 PriniedfTyped Name wIT l <br /> a r'" A~ I Month Day Year <br /> Signature <br /> Z Transporter 2 Printedlryped Name <br /> 19 <br /> r 18.DiscrepancyFull Reje M <br /> 18a.Discrepancy Indication Space ElQuantityType <br /> ❑Residue partial Rejection El <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b,Altemate Facility(or Generator) <br /> V <br /> Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) 4 <br /> 2. <br /> LU 1. H 141 <br /> 20.Designated Facility Owner or Operator:Certification o receipt of hazardous materials covered by the manifest ex as noted in Item 185 Da ear <br /> 5ignatu �y <br /> Printe ams nI (/ <br /> IF <br /> EPA Form 704-2 R v.12-i7 Pr vious editions are obsolete. �} �UGN�ITED�ACI PA'S e-MANIFEST SYSTEM <br /> C�eaf� I I ors h�s the appfopnate permh for and will accept the waste the goner JEERS s Ippf <br />