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SSL SK SHIP# 238, 77 <br /> Please print or type. <br /> 1.Generator ID Number FOrmIMProved OMB No.2050-0039 <br /> V <br /> RDOUS 2.Pa of 3.Em R ePhoog� - C:Menifeat Tracking Number <br /> EST Com-000394668 1 1 ib® O.o 7 r�7 C C 7( '..SKS <br /> and Mailing Address Ganeretofs Site Address(if digerent man rtnWng ed0ress) f J V <br /> y # 4719 <br /> Harlan Rd <br /> CA 95330-9802 <br /> Generator's Phone: 205-234-1895 <br /> s.Tr�g ty- ,y � SYSTEM^Iii U.S.EPAIDNumbar TXR000081205 <br /> 7.TransponerLEA 2 Company Name �ft U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> e.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA IDNumber <br /> 1021 BERRYESSA ROAD <br /> 408-441-0962 SAN JOSE 7 CA 95133 <br /> Facllirys Phone CRD059494310 <br /> ga. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12,Unit 13.Waste Codes <br /> No. Type Quantity WLNo1. <br /> X 1 RQ UN1993 NASTE FLAMMABLE LIQUIDS DM P F00 F802 F0/D3 <br /> o N.�}.S. MLENES BENZENE) 3 PS I1 <br /> (D001)7 ' 7 ' 00 Foil 1001 223 <br /> W <br /> (� was7 <br /> t 7 <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Information .Y JDiS.I 82294045 R1617�in <br /> y jj{ <br /> 1)ERG#128• 1 24H EMERMNCY#800-468-1760-CH/SK/TFI-Contrac�_�^Vd by ,getor confers a ency authari y <br /> on initial trans orter to add r substitute additi n I transo on enera r7s a alf. <br /> 15. GENERATOR'SIOFFEROR'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, i <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and[am the Primary <br /> Exporter,I cerliry that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Cc enL I <br /> I curtly that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b 1 am a small quantity generator)is We. <br /> n erors PnntedfTyped Name Signature , MonthDay Year <br /> e� 7 .&. i <br /> J 16.International Shipments - Gr '.. <br /> H- <br /> El Import to U.S. ❑Export from U.S. Pod ofentry/exiE <br /> S.Transporter signature(for ezpoRs only): Date leaving U.S.: P <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tryped Name 9 <br /> po Printed/T nature <br /> � <br /> Y11 2, <br /> Day Year , <br /> 2 7 <br /> i ner2 rintedR ame Signature 1 <br /> Month Day Year <br /> z <br /> .Discrepancy <br /> 1 <br /> 18a.Discrepancy Indication Space ❑ Quantir <br /> ty ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> I <br /> Manifest Reference Number <br /> 16b.Alternate Facility(or Generator) <br /> J U.S.EPA IDum <br /> Nber <br /> U t <br /> LL Facility's Phone: .+ <br /> WQ 16c.Signature ofAltemate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste aeatment,disposal,and recycling systems) <br /> 1. / 2. 3 <br /> 4. <br /> i <br /> 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by me manifest except as m Item 14a <br /> Pnntedrryped Name <br /> Signature Mon Day f <br /> EPA Fo[q�N7, �(g -1 eviowoopm SIGNATED FACILITY COPY <br /> 1 SIBILITIES UNDER THE e-MANIFEST ACT.SEE/INSTRUCTIONS ON REVERSE SIDE. <br /> �' <br />