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,w <br />4 • <br />4Sf r tvira IFnnn desinnad yrc r ion nn ame ?I I a.a.1 a.,......u... <br />®ESIGNATED FACILITY TO GENERATOR <br />[Ito <br />corm Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS t Generabr ID Number 2. Page 1 d 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST O O Z T� 9 9 41 FLE <br />S, Generators Nemeand mailing Address <br />' <br />eratorsAddrees,in dierent man mailing cess) <br />Dal ics to Yiracyerdc <br />12001 9 Highway 99 <br />markteea, CA 95336 <br />Generators Phone: 111101, AIA <br />B. ransponler 1 Company Name <br />U.S. EPA ID Number <br />r <br />7. Tmnsponar 2 Company Name U.S. EPA IO Number <br />�° /77f%JO 3J J <br />B. DeeigrWAd. FedlAy Nemaand aC. rra. <br />U.S. EPA ID Number <br />Clean Bezbors of sass Jose, LLC (Nark JosePacilityy <br />2021 6arryeeeo Road <br />Nan Jose, CA 9s133 <br />facitty's Phone: _ <br />Sea_ <br />0b. U.S. DOTOwdintdn plMucing Proper Shipping Name, Heard Class, ID Number, <br />50. Conlainea <br />11. Total <br />QUA <br />12. Unit <br />_ <br />1,541,444444- <br />NM <br />and Packing Gmrefd aniNo. <br />Quersity, <br />MJVt, <br />13, Waste Codes <br />Type <br />o <br />1. <br />® <br />T3i <br />w <br />2 UNi;(63, WASTy� i?A+r1C G2b`aLAZ��7 F+'�0.�aZlA�-� <br />� <br />1�t1� 33 <br />3Un111'70e WP(STE ETilai-It Amo T SotaJRcT(u <br />Lel <br />31 PGS% <br />JJ1 <br />�J <br />P <br />4. <br />14. Special Handling instructions and Additional hdorme7on <br />a)e.N4o�3b't; >-901 CI x 56.oh� <br />Project s.rNar: Cvoosa7 3'r --A <X310 j 0EG—'1Q.ZCj x.154 OiT;�)I <br />15. GENERATOR'S)OFFEROR'SCERRFICATION:Ihereby declare mat the contents of this witsignmem are fully and accurately described above by the proper shipping name. and are classified. peoleged. <br />marked and Iabeledlplaarded and Min all respects in pmpermnditon for transport according to applicable international and national governmental regulators. If eapwt shipment and I am the Pdmery <br />Exporter, l oerliry, mal this contents of this oonsignrnem mnform to this to" of the awed EPAAcknveledgmenl of Consent. <br />I certify mat oe wash minimixaton Nrkmont identifed in 40 CFR 26227(a) if I am a large quantity Vendee) or (b) (Irl am a small quantry, generator) is We. <br />YPbelime, M Dorm ear <br />Ty 14AN� r Q �3 <br />—r <br />18. International Sit,twis <br />ImpmMU:s. ❑FaputhonV.s. Partdmhy)axit Cil1 <br />T2re " nature for exmints N <br />Date leaving U.S.: <br />Ir <br />w <br />1LT ranapmsAaeoAtedanemdRecebtdMeatea li <br />Transporter 1 PfirtediTY ame Month ay year <br />AEt 1R`Z �c �C�SQc t C7 3 Cfi <br />7arnpodar2 PrkmteNfyped Name Signature <br />Gy air <br />* <br />18.0isaeparrry <br />18a. Discrepancy Indiatr Space n ❑Type ❑Residue ❑Partial Rejection ❑Full <br />Rejection <br />Mandesf Refinenm Number. <br />lab. Alremare <br />U <br />y <br />V <br />T'7\ U.S. EPA IO Number <br />LL <br />FaciIl Plmm: <br />raga <br />FY <br />1.&. Signature ofAllemote tor Gaineratpr) monih Day Year <br />1g. Nowtlwa Weare Report Me ethos Cotler (i.e., codes for hazandu n, waste treameni, disposal, and "Ing systems) <br />2. <br />20. Designated Facility Owner or Operator. Certification of1ecd�pt of hasuamous m ustalls covered by me manifest a coed in gem Its <br />1 <br />Prb Name ntoW`/� Sl9naWre ! / Da� year <br />M11w/ Day <br />r <br />FPA <br />Finn A7nnSp yew <br />®ESIGNATED FACILITY TO GENERATOR <br />[Ito <br />