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SK SHIP# 231446154 111111I11111111loll 111Ib11111111 <br /> Please print or type. 0 0 7 Fomt Apprwet7.&A 11o.2050-0039 <br /> 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAI_000394669 2.Tel of 3.Emergep44�'RQspp¢se Plhgp � KS <br /> WASTE MANIFEST IF 1 tSIP Vb+i 007461720 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> n) Rei13y # 4719 <br /> 15074 S Her:•Ian Rd <br /> I_ATliRilt-' CA 35330-991@2 <br /> Generators Phone: 209-234-1895 ' <br /> c U.S.EPA ID Number TXR000081205 <br /> 6.Tr�yyu�r4�Companv_Name SY.�TEMS INF <br /> 7.Transporter 2 Com�ppatn�y�Name U.S.EPA ID Number <br /> iFPN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 CAD059494310 <br /> 4018-441-0962 ' <br /> Facility's Phone' , <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group Qf any)) No. Type Quantity Wt.Nol. <br /> X 1. Rt? HN'QQ3 WASTE FLAMMABLE LIOUIDS DM I�� P F001 F00'2-F003 <br /> F N.h.S. , {XUNES, BEN7ENE) , 3, P5 I (P f <br /> F00 D0:01 22-1 <br /> z 2. _ , <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD a,.I R3i'"c.'8C:67 11R16176 ,,k <br /> i)ERr#i28 aoa5 ds <br /> 24H EMEP,G✓ NCY#800-4F8-1760-CH/SK,/TFI-Contract retained generator confers a'enr_ylauith ri y <br /> Or initial r r to add or substitutpe - . s hehAlf, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately desated above by the proper shipping name,and are classified,packaged, <br /> 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 <br /> -Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Con nt. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) 0 m a small quantity alor)is true. <br /> GeneatorsiOfierors PrintedRyped Name Signature Month Day Year <br /> 105113 WO <br /> 16-International Shipments ❑ ❑Export from U.S. Portof en /exit: <br /> Import to U.S. M <br /> ? Transporter signature(for exports only): Date la ing U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> TmnspoQer 1 Printed ype ame Signature Month Day Year <br /> a 11 <br /> Z Tanspo er 2 PrintedR <br /> yped Name Sgnatu u , Month Day ear <br /> j18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Farrel Rejection ❑Full Rajedion <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> C) <br /> rai Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) - - <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility OOperator:Certification of receipt of h rdous materials cover the manifest ezcep nded in IW <br /> wner or <br /> Printedlfyped Name Signature Monts Day Year <br /> EPA Form-8700-22,Rev.12-17) Previous editionsMA obsolete. DES ATED ILITY TO EPA's e-MANIFEST SYSTEM <br /> �7 X.A/ 03 <br />