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Please print or type (Form desioned for use on elite run.,,, n.n r <br />trK roan Deco cc lnev. a uok rravmous earuons are closaiete DESIGNATEjY ACILITY TO GENERATOR <br />r C/ <br />roan r�pprovea. vents NO. Ztrb114103: <br />UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3. Emergency Response Phona 4. anffast Trac ng Number <br />WASTE MANIFEST � $9®Q9QQ02 7 925-423-4205 r JJK <br />5. Generator s Name and Mailing Address Generator's Site Address fd different than mailing address) <br />Lawrence Uve7nore N300nil UtumSory SFe 300 r <br />P.0 00x 806 tw786 LLhIL SAX <br />LPfOrMore CA 94551 COTd1 HOUM 8030 10 Mlles So111h West <br />Tracy CA X376 <br />Generator's Phone: 423-422-1925 Atta: 8hippiag <br />6. Transporter 1 Company Name <br />S. EPA ID Number <br />Clean Harbors ErrrBanrrisMal Services Inc. htu'ElvmY.MM039322260 <br />7 Transporter 2 Company Name U.S. EPA IDNumber <br />(i � AMA O ' 014 '"i T' <br />6. Deskgnetad FacNiry Name and Site Address U.S EPA R1 Nu*hbe• / ,. <br />Clean HaTirs of San Jose, LLE <br />1021BeneesaFoal ENVIRONMENTAL HEALTH <br />San Jose CA 95133 caD45��a�ao <br />F8CW3Phone: 40 8 _03 —Moo DEPARTMENT <br />ga <br />Bb. U.S DOT Deaafptlon Qndudng Proper Shipping Name. Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Pecking Group (N ii <br />Ouentlry <br />WtNol. <br />13. <br />Waste Codes <br />No <br />Type <br />lY <br />1.NA1993.'Waste, Diesel fuel rrixture, 3, 111(ERG 1281 <br />0 <br />343 <br />1 <br />Ilii <br />10 <br />P <br />LU <br />2 UPl1192. Waste Ethyl lar 3, III (ERG 129] (DCPM%11 <br />331 <br />i <br />DF <br />501 <br />P <br />D001 <br />3 LIM 192, Waw, ct+r.-1 lactase 3 111 (EPG 129] (DOP0054-1) <br />33Z <br />1 <br />DF <br />505 <br />P <br />Di <br />4 LIN 1193, V+ta ?, M. Oth%-1 bpi ketone mixture. 3, It (ERG 127] <br />(DOPQCm54 1) <br />34a <br />3 <br />DQCI <br />14. Special Handling Instructions and Additional Information <br />Er1>argenui Response Ph. L 925423-42Q5 Conte narne LU -,IL Er-p7-2n.�, OisQat' Load #t <br />C-11'5- 1?, Ship Doc ND S-17?899 Petere.ice reie3sen:lr>iber LLROSOI? on involce See <br />attached for contzii ter nunters SJAPCO 4230 Klerria.-I Ave. ST& 13]1, Mode -=to, CA 95356 <br />15 GENERATOR'SXIFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fitly and accurately described above by the proper shipping name, and are classified, packaged <br />Akarked and labeledlplacarded, and are in atrespeds in proper condition for transport according to applicable international and national governmental regulations If export shipment and I am the Primary <br />'!'Exporter, I certiy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if 1 am a smaI quantity generator) is true <br />GenerelorslOf(erorsPMnledrrypedName Signature Month Day Year <br />Scott A_ G r tater -nne SA [I1 <br />4 <br />-j <br />F- <br />16 International Shipments <br />❑ Import to U S ❑ Export from U 5 Port of entry/&d _-------- <br />Z <br />— <br />----------- <br />Transporter <br />po signature (for exports only) Date leaving U S <br />w <br />17 Transporter Acknowledgment of Receipt of Malenals <br />Mer 1 P yped Name Smgnat Month Day Year <br />a— <br />En <br />4T r __ l <br />ZZ <br />cer 2 `.. Name — <br />Signature Month Day Year <br />18 D;,rroancy <br />18a Discrepancy indication Space ❑ Ouenbty ❑ Type ❑ Residue Ll Partial Rejection ❑ Full Reiedion <br />Manifest Reference Number <br />18b Alternate Fanfrty (a Generator) U.S EPAID Number <br />a <br />U <br />FadGty s Phone <br />18c Ignatured Altemate Facilty (or Generator) <br />Month Day Year <br />QW <br />2 <br />N19 <br />Hazardous Waste Report Management Method Codes (I e , codes for hazardous waste treatment, disposal, and recycling systems)LLJ <br />G <br />1 H/� I <br />2 H! <br />I <br />20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as n Item 18a <br />rintedrryped NSignature Month Day Year <br />4a 0. A'I <br />�1 <br />06 <br />trK roan Deco cc lnev. a uok rravmous earuons are closaiete DESIGNATEjY ACILITY TO GENERATOR <br />r C/ <br />