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Please orintor:tvDe%(Form desionedfor use onelite (12 -nit.. jewriter.) C�f4 s P )905lM FnrmAnnmvAd (SMR Nn 7nsn_nnAQ W UNIFQRM HAZgRDOU$ IiUA$TE'AIANIFEST 1. Generator Number C A H 1 I 9 0 `a 0 9 2 Page 1. of 2' 3. Emergency Response (Ifs) 4e3- 4. Manifest Tracking Number 0011 F L E 5. Generator's Naa and Mailing Address Generator's §kAddress (if different than mailing address) County Cif gan JoafKn - Tt2a1 I $ ! € Hqu I fvoi Ave Sty F3%7u!LIIVM 5f VC k Fa ra (�} 20182411; 9tyrm. T1 South Til Boulevard �5 Tracy, CA q�377 Generators Phone: 209 408-30015 ATI'N-.K Andrews 6. Transporter 1 Company Name U.S. EPA ID Number - Clean Harbors Env Services Inc M A CI 0 3 9 3 2 2 2 5 0 7. Transporter 2 Company Name U.S. EPA ID Number } i S, dire U.S. EPA ID Numtiet-' i 1021 Ben-yessa Road C A Q 0 5 9 4 9 4 3 1 0 San Jose, CA, 85133 Facility's Phone: (408) 40-00152 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WCNoI. 1.FLAMMABLE UQU DS, TOXIC, N.O.S., t-PYRETHRI 01A.ZINON o ga ?� (HH>#v)) . 3 , (6.1), UN'i 99 , PG Il +... .J ca; s w (L') X ..H YPOCHL.C}RITE) , 5.1, Utll313g, PG II C� 3.. X (HYDROCHLORICACID, SULFURIC ACID) , 8, UN3264, PG II fa. � yj� _ �1., x 4. -- ., , OXALIC ACIP , S, UN3255, P(3 II IMSp ,Arupkna. Cti'2466W 7 1 LRG#154 2. CH24OSM 3 x 5s - ERt0140 4- C11i2AM24 -`.P�7ERG*153 SCWCJ1492MS Fleet #fi 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fullyandaccurately described above by the proper shipping name, and are classified, packaged, marked andlabeled/placarded, and Are in all respects in proper condition for transport according to applicable international and national govemmental regulations. I( export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste mire6zation 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. Generators/Offerors Printed/Typed Name A f f y1e f+{iHt*S F p 7igna ure Month L)ay---7e-ar i E' h a r d L. I✓t ( I ear S°r "+ 7 o C L-4 r' ( u L4 4 1,Y.+�.d"` 6 p j D � 16. International Shipments ❑ : Import to (}:S. El Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U S.: W 17. Transporter Acknowledgment of Receipt of MaterialsKnAl AfRfrl Transported Printed/Typed NaSi atur o%t Day 6 Year a CO) 1114 is - I I l.N Transporter 2 Printedrryped Name Signature Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection (VmtSVV) 1 x55 tY11n lrrarn L -WIG V78 6 Rem()1IF0 i OF ffDw\ Wre VB $ t0✓ MPNICD Manifest Reference Number: 18b. Alternate Facility (of Generator)" U.S. EPA ID Number J Q w Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z u, 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 1 4. ,29-G.signatedFacitity.OwAer,or.Qpgtor Certification of receipt of hazardous materials covered by the manifest except a n ted in Item 18a Pr yped t/` .._..:. ......-_... Signature .... .. _ _- 0 �jonjh Day, Ygs3�j � ��yy//�]a% �/ G WOMWARWOdWeAnd will awept me a ane �ptng. nFSI AT FACILITY Tn GENERATOR W