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bK SHIPS iIIIIIIIIINIIIIIIIIIIIIIIIIIIIIIII <br /> Please print or type. 23 �^ 0 0 8 3 1 4 4 2 5 S K S <br /> Fo m Approved.OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 4.�er7lteaiTrgpklrlp Nlyngpr <br /> WASTE MANIFEST L L���ucili�+1 2Pled l(U1�S911'44+(C�]J 25 SKS <br /> 5.Generators Name andMatling Address Geaeralofa Site Address(litllfrarent than maMing address) <br /> 5etnstate Equlp�ent Sunstate EquipMent <br /> 555 E. Washington St, Attn: AnnaE Bodell 75 E Equipment Lt <br /> PHOENIX AZ 950.34-0000 <br /> Gen....Ws phone r=0c 40E f IS7 FRENCH CAMP CA 95?31-0001 <br /> 9-99" }—`rTPN SYSTEMS INC u.s EPA ID Number <br /> 7,Tnanspoder2 twpany Name 0S.EPA IC Number <br /> CLEAN HARBIBK) ENV SVC INL. <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE 11.5.EPA iO Number <br /> 1021 BERRYESSA ROAD <br /> SPIV JOSE � CA 5513:: <br /> 40S-1+41—O'fE.. <br /> Faciiiry's Phone: CAD059434�1 @ <br /> ga. 9b.O.S.DOT Description(including proper Shipping Name,Hazard Class,ID Nun-der, 10.Containers 11,Total 12,Unit <br /> kM antl Packing Group(if any)) No Type Quantity Wt Mol 13,Waste Codes <br /> 1.NlsN—RCRA HAZARDOUS WASTE SOLIDS, um P L:=3 <br /> a kDEBR15, PETROLEUM HYDRGLARSGNSr <br /> W <br /> W 2 <br /> C9 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions andAdditional Inlomradon ,_j <br /> 3E13.lJl-H¢, c: <br /> L41-r r L�T• t .., retained by gen+ar•atoT <br /> I . _. Rons Drter to acts or• suustitute additional trans orters on <br /> 15. GENERATpR'Si4FFEROR'S CERTIFICATION!I hereby declare that the contents of this conaignrra:ni are fulry and 8m mlaly described above by the r d k<_a i <br /> marked and labeledlplacarded,and are in at I res paper shipping nanre,and are classified packaged. <br /> pacts in proper condition far transport according to applicable mtamatidnat and national govemmertfal regulatwns.if export shipment and I am the Primary <br /> Exporter,t certify that the contents of the consignment conform the terms of the,attached EPAAcknowladgment of Con <br /> I cEmfy that the waste minimiaaaan statement idenfdied in 40 CFR 262.27{a}(I I am a large quangly generator)w(b) a sm Guano q is true. <br /> Genora CRemrs PrinledRyped Naas Signature <br /> Month Cay Year <br /> 1.int ational Shipments -2 �•Z <br /> ❑Import tc 11.9. ❑Export from t1,S Port DIG drylexit <br /> = Transportersignature(for exports anlyp Cate leaving t1.5. <br /> w17,Tr insporlerAclinoWedgmonl of Receipt bf Materials <br /> Trans er 1 PnmetllTyped Name <br /> Si ore <br /> a /J Mortar Day Yeas <br /> Z 2 Pnniedrr (Jame �') signatun: r•G,— <br /> Month Day Year <br /> 19Discrepancy ';?_ <br /> 18a.Discrepancy Indlcahon Space <br /> ❑Quantity ❑ <br /> Ty, ❑Residue Ll partial III ❑Full Rejection <br /> 18b.Alternate l itp{or Generator) ManHesl Reference Numtrer <br /> U S.EPA ID Number <br /> V <br /> ra Facility's Phona, <br /> C3 18d.Signature ofAllemam Faality(a Gens ia) <br /> Q Month Da., Year <br /> z <br /> V) 19.N22ardoaa Waste Report Management Method Codes(i.e..codas far hazardous waste treatma#,disposal,and recycling systems) <br /> jPr1rt.�yp_ed <br /> I 2. 3 ed Faafiry Owner or Oaerator:Certrica&on of receipt orhaxardous materials covered by the manilas!except as need in Item 78aQ N me ` 9gnaturs Sl a I p Q_�} Month Day year <br /> EPA Fp m fl7p0,-22lRev.]217 P eviLLoaVs call oVnsVare obsolete, pESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> n X70. 2r v.14-IJJ F!! <br /> ,v <br />