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SK SHIP# 21284400023 Please print or type. Form Approved . OMB No. 205010039 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number UNIFORM HAZARDOUS 'f?l.` {?l �F�' 1;\til i . ; i ; t: i' , t;` 100 r� sN 1 41 ' � � WASTE MANIFEST 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) I... f3V . clC4F-4 I7ic"t '?' Q, iatl R@.'C_` �+ C` �. 1T? U Center ace Rd 'Ir' ITt'. 0 I.. t -i �" � [�}_. i��;i Generators Phone: ' 'fir • ' 1 U.S. EPA ID Number _ 6. Transporter 1 Company Name t° 5 i'' ?:, -r I �. Yl-1i...��1 ` Y iT• 1+x;3 1. I'•IL: 1' r`�. i'iti'1 ti>(!l t �. rr�r. , 7. Transporter 2 Company Name U.S. EPA ID Number CLEAN HARKIRS F,V1VIM1qMFNTAL SVC TIT • 8. Designated Facility Name and Site Addressor`r c U.S. EPA ID Number (:;l_l.AN HARBORS ii- ita . E 1 021 BERRYES83A ROAD SAN OSE v CA 95133 Facility's Phone: 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit 13, Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 1 . NON� RC'. RA 4-lt`4MMOUS WASTE , SOLD t ' 1 o ( 1,11L FILTERS ? ,. ' 2. Lit] 0 3. 4. I 14. Special Handling Instructions and Additional Information t 4: - . ID r , ; ._, ( Ct• I, �, r• C, Graf' � ;,I.1 i E l{:,1 :1+.! t >'t ire, t - � frfi y qe e or rAiconfers agenev ca ;.R, . 110r1 , tri cc Ger ^ : - 7 'rr T.I. • % 7sYIf , •-iIt _ � •,- rA1A " ' 0i, ? r F : - Y :» 15. GENERATOR'S/OFFEROR'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, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment cenform to the terms of the attached EPAAcknowledgmenl of Consent; I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. I Month Da Year Generators/Offerors Pdntedlfyped Name Signature Y =j 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S W 17, Transporter Acknowledgment of Receipt of Materials LLJ Tratf$poder 1 Printed/Typed Name Signature f: Month Day Year a A za Transporter 2 Printed/Typed Name Signature Month Day Year fl 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number L) Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LLJ 1 . 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdnted/Typed Name Signature Month Day Year i i EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR' S INITIAL COPY