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00153146675 K5 <br /> :nt or type. �—.J� Farm Approved.OMB No.205x0039 <br /> y LINIF6RM HAZARDOUS 1-Generator IU Number Ps 1 of E 4. rifest T g H tuber <br /> CAL00039L 478 - - 6�8rTj T 6 6 7 SKS <br /> 51AIASTE MANIFEST <br /> 5.Generator's Name a M dress Generators Site Address(if different than mailing address) <br /> Ol Ilei 1 y # 2567 <br /> 144th E �farding. Way <br /> S10CIT0N CA 95205-3104 <br /> Gerwato>s Phone: 972-555-1247 <br /> 6.bj?9V'.c.yA meSY5TENS INC U-S-EPA ID Number T n R000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> EI..-EAN HARLAQRS ENV 5VC= INC, <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U-S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SANJOSE , CA X51:;3 <br /> 406--441-0962 I:AD059494310 <br /> Facility's Phone: <br /> 9a. gb.U-S-DOT Description[ncluding Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12-Unit <br /> HM and Packing Group fdany)) No, Type Quantity WtBol. 13.Waste Codes . <br /> 1.mi.]dEANON—RCRA HAZARDOUS WASTE SOLID, � �- P 172. <br /> 4� <br /> ME7DUST AND MACHINING WAST L 17E), <br /> SIA � <br /> Z z. <br /> w <br /> c� <br /> 3. <br /> 4- <br /> 14-Special Handling Instructions.and AdditionalInformation TSD:S.I 8821-01.28 OR14384 CSCE <br /> 24H EMEPGL�'NCY#800--469-1760—CH/SK/I'FI—Contract retained by gener-atur confers aency autharit ' <br /> on anitial transporter to add or substitute additional transporters on eneraMIS behalf, <br /> 15. GENERATORWFFEROWS CERTWICATIDH: 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 Iabefedrplecanded,and are in all respects in proper conation for transport according to appl cable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,t certify that the contents of the oorogmxnt conform to the terns of the attached EPAAdmoWedgment of Consent- <br /> I certify that the waste minimization statement idenitfied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b){d I am a v quantity generator}is true. <br /> G atorWOfferors Printedffyped Name Month Day Year <br /> 01-5 14 <br /> _j 16.International Shipments <br /> F-- ❑Import to U.S. ❑Export from U-S. Port lett: <br /> 9 Transporter signature(for exports only): Date leaving U-S.: <br /> W 17.TransporterAdmoWledgment of Reoeipt of Materials <br /> T orter 1 PrintedfF meSg Month Dray Year <br /> a <br /> Transporter 2 P•tedfTyped Name Signature Month Day Year <br /> r <br /> 18-Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue Rejection ❑Full Rejacbm <br /> Manliest Reference Number- <br /> 18b.Alternate FacAity(or Generator) U.S-EPA iD Number <br /> J_ <br /> V <br /> Fadi ty s Phone! <br /> W 18c-Signature ofAltemale Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,ctisposal,and recycling systems) <br /> LLI 1. 2. 3. 4, <br /> 20-Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature mrd' . <br /> EPA F 8Wdl[R(gv4M,1 } Previous editions are obsolete. DESIGNATED FACILITY TD EPA'sMANIF <br /> 3 41% <br />