Laserfiche WebLink
SS1 SK SHIPN c, raR�7e►`.� <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mandest Tracking Number <br /> WASTE MANIFEST I'M 1/300904�7(A 1 Fll�0 461' -I 17 r 00609.9889 SKS <br /> 5.Generatofs Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 115 Portal Service <br /> 3131 'arch Airport Ril Sacramento <br /> C,RICK f(IN CA 95P13-3k101n <br /> Generators Phone: ?1b9"��83-ti31f� <br /> 6.Tranrter 1 Company Name U.S.EPA ID Number <br /> SATYT`-1-KL-4EN SYSTF+iS INC TXRQ4 0081?0: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ("I f=ntJ HARBORS ENV I RONMF_NTA1. SERV ICIES INC- <br /> B. <br /> N'O8.Designated Facility Name and Site Address CLEAN HARBORS STAN JOSE: U.S.EPA ID Number <br /> 1c111211 BERRYFSSA ROAD <br /> SAN JfISF CA 95133 <br /> Faali 's Phone: <br /> "4.468 •A,141-Q'=)li: (;tj1)0 )'34'i4.31E'I <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wl.Nol. 13.Waste Codes <br /> 1 i;'_IN F[:H0 HC/0Rlu0,1; WASTF SI.X_IDS, (HRAK !!A'e F' 1 <br /> o r 1NUIN(i` } <br /> 4a <br /> w2 ° ° <br /> O KEU �I <br /> 3. i <br /> 4 <br /> )EPA RTM <br /> 14.Special Handling Instructions and Additional Information I ED EJ 9 US 18590 CSS: <br /> 24 NN E14FIRGFNCY t►1-+i00 wii -1 lritb OiK / •(1= 1) <br /> C.�i --FY - ) u - <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, <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 I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Admovrledgment of Consent <br /> I ce"that the waste minimization 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. <br /> Generator's/Offeror's Printedfryped Name Signal Month Day Year <br /> -J 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Race#of Materials <br /> IX Transporter 1 Printed(Typed Name Signature Month Day Year <br /> O <br /> a <br /> 7d- Transporter 2 PrintedfTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ouantity ❑Type ❑Residue ❑Partial Rejection ❑Fu!Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZZ <br /> as19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 1)776'3P-i'114P199 <br />