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SSL SK SHIP# -- iiiliiffil IilNl�li illlili Ilii <br /> 0083946678 KS <br /> Please print or type. L( Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator tD Number CAI_000.39247 t 3.Ere cyRgsppns P r{g 4.�aO�7r kirjg Tgr� �� <br /> WASTE MANIFEST 1 fU-4tr19 f'�r�1 U 14 6 <br /> 5.Generators Name and Mailing Address Generators Site Address(9 different than mailing address) <br /> 4' Reilly # 2557 <br /> 1440 E Harding Way <br /> STOCNTON CA 95205-3104 <br /> Generators Phone: 972-555-1247 <br /> 6-0 1-A9L V SYSTE14S INC U.S.EPA ID Number T X#1000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN -HARBORS ENV SVC INC. MAD]039322250 <br /> S.Designated Facafty Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 HERRYESSA ROAD <br /> SAN JOSE CA `351 33 <br /> 408--441-0962 CAD059494310 <br /> Facility's Phone: <br /> go- 91a.U.S-DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity WtNol- <br /> 1�E , NON- RCRA HAZARDOUS WASTE SOLID11 j 4)w P 172 <br /> o 01ET ILL DUST FIND MACHINING WASE 172)1 [ �� 9- <br /> 3- <br /> 4. <br /> 3-4. <br /> 14.Special Handling Instructions and Additional information TSD'SJ BBB-10128 OR 143 CS6; <br /> a\ ���y L��( t <br /> 24H EMERGENCY#800-46A-1750--CHiSK/TEI�-.Contract retained by enerator confers agency au hd <br /> oT1 initial transporter t0 add or substitute additional t parters ongenerator's behalf. + <br /> 15. GENERATORWOFFEROR'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 Iabeledlpfacarded,and are in all respects in proper condition for transport according to applicable intemadonaland national governmental regulations-If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. r <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a vAquantity generator)is true. <br /> G eratorsJOtferors Printedfryped Name re Month Day Year <br /> K <br /> r rks-'s !"k 9,6� 17 0- . <br /> 16.international Shipments <br /> F El impost to U.S. ❑Export from U.5- Port lexft: <br /> z Transporter signature(far exports only): Date leaving U.S.: <br /> I= 17.TranspDoor Acknowledgment of Receipt of Materials <br /> T s er 1 PrintedIT ame Sgnatu Month v6" <br /> Day Year <br /> 1� <br /> a Transporter 2 (Typed Name Signature Month Day Year <br /> t— <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Rejection <br /> Quanliy Type ❑Residue mal Rejection Full ReIect <br /> Manifest Reference Number: <br /> 18h-Alternate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> V ' <br /> Faplity's Phone: <br /> Fa ISc.Signature of Alternate Facility(or Generator) Month Day Year <br /> x <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4, <br /> 20.Designated Facility Owner or erator:Certification of receipt of hazardous materials covered by the manifest exc4#as noted in a <br /> Printedfryped me gnatu Month Day Year <br /> t7 <br /> Ell V4i6 fWd �gvv4g 16,Previous editions are ete. DE NAT FACILITY TO EPA's e-MANIFEST SYSTEM <br /> is 8�� <br />