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.K SH I fin# 222195913 <br />Please print or tvDe (Form desioned for use on elite 02 -Ditch) Noeviter ) <br />FrianAnnmvPd OMR Nn 7f1g11.11n74 <br />EPA Form 8700.22 .,Rev 3-05 Previous editions are obsolete <br />1)7949332/142173:: <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />I Generator ID Number <br />2 Page 1 of <br />3. Emergency Response Phone <br />Z Mantfest (racking Number <br />WASTE MANIFEST <br />CRL000329569 <br />I-eiVA-4b <br />SKS <br />5 Generator's Name and Ma ing Address Generator's Site Address (d different than malling address) <br />hiinack Construction — Bird Road Shop <br />23G23 Bird Rd <br />TRACY CA 95304-0000 <br />Generators Phone: 510-50G-3223 <br />5 Transporter 1 Company Name U.S EPA ID Number <br />A�ETY-KLL-EN SYSTEMS INC TXR000i081n� <br />7 Transporter 2 Company Name U.S EPA ID Number <br />8 Designated Fadldy Name and Site Address CI FAN HARBORS SAN JOSE U S EPA ID Number <br />IINPI BERRYFSSA ROAD <br />SAN JOSE , CA 9513395133+.08-441-095? <br />CAI)059494310 <br />Facility's Phone: <br />ga. <br />9b U.S DOT Description (mdud:ng Proper Shipping Name Hazard Class to Number <br />10 Containers <br />11, Totai <br />12 Unit <br />13 Waste Codes <br />No <br />Type <br />HM <br />and Pack6g Group ('t any) <br />Quantity <br />WtNol <br />Ix <br />X <br />1. NA3092, HAZARDOlh' WAtiTF LIQUID, <br />9, <br />N.O. S. , (BENZENE), Pt; 111 <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instruclions and Addilional Information TSP s SJ 73488544 SH23349 CSG: <br />`0 ERC#171i�� <br />� R4HR EMERGENCY #j-800-468-1760 (SK / TF'I) <br />jj2jITt4 n. nhrL . t—t^n rr AV r.IZN T r rn I T T= Qt=T) Clin rnqPTFUC 5 t q� <br />�( GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are d2ssi6ed, packaged. <br />marked and labeledtplacarded and are In all respects in proper condition for transport according to applicable international and national govemmental regulations. If export shipment and I am the Primary <br />Exporter I cenily that the contents of consignment conform to the terms of the adached EPA Acknowledgment of Consent <br />I certify that the waste minimization stalemerct 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 />GenerafoesiOfferoes Printed/Typed Name Sgnahse Month Day Year <br />.J16. <br />t- <br />inlemational SMpments <br />❑ Import to U.S ❑ Export from U.S. Port of entrylexit <br />M <br />Transporter signature ;ion exports only) Date leaving U S <br />X <br />17 TmrmportefA.dmawledgmenl of Receipt of Materials <br />j� <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />O <br />a <br />rn <br />Q <br />Transporter 2 Prtnied/Typed Name Signature Month Day Year <br />ti <br />18. Discrepancy <br />IBa Discrepancy Wication Space r — <br />Qua"tity ❑ Type ❑ Residue Paftol Rejection ❑ Ful Rejection <br />Manifest Reference Number. <br />18b Altemate Facility (or Gereratorl US EPA ID Number <br />J <br />U <br />I' <br />Facifitys Phone <br />w <br />18c Signature of Alternate Fac ty ;or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e codes for hazardous waste treatment. disposal, and recycling systems) <br />1 <br />2. <br />3. <br />4 <br />20. Designated Faciiity Owner cr Operator Certification of receipt of hazardous materials covered by the manifest except as noted in tem 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700.22 .,Rev 3-05 Previous editions are obsolete <br />1)7949332/142173:: <br />GENERATOR'S INITIAL COPY <br />