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?t IL 91 OP# 2138:36935 � (III I I�II I I II�III III I III II I III <br /> 4 +) 43743855 K5 <br /> Please print or type.(Form designed for use on elite(f 2-pitch))Wwriter.) Form Approved.OMB No,2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3. 4!;4'Rtogse PflO�.e , 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAL000145595 1. ._f<�;.:,_.,.,r. -:, 004374385 <br /> 0 n 3 7 3 p[ SKS <br /> WASTE MANIFEST �# 4 G�1 nV <br /> 5.Generator's Name and Mailing Address Generator's Site Address pf different than mailing address) <br /> My Transportation 9 <br /> 1x50 S Wilson Way Ste Al <br /> Stockton CA 95205-7026 <br /> Generator's Phone: 831-394-4100 <br /> T �1° SYSTEMS, INC. U.S.EPA ID Number TXR02�0QrP1^'5 <br /> -;•=spoiler 2 Company Name U.S.EPA ID Number <br /> ?.Desgna:ed Facility Name and Site Address CLEAN HARBORS SAN JOSE, LLC U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 951,3.? CAD059494310 <br /> 'h08-x41-0962 <br /> Facilil�s Phone: <br /> 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group('d any)) No. Type Quantity Wt1Vd <br /> t. NONE NON ?CRA HAZARDOUS WASTE SOLIDS, P <br /> o (DEB4IS, PETROLEUM HYDROCARBONS), N/A <br /> a <br /> w <br /> w 2. <br /> O <br /> 3 <br /> U.Speaai Handling Instructions and Additional lnknination TSD:SJ +499624 MVi�01r <br /> 24 HR EMERGENCY #1-•800-468-'•1760 t f(SAFETY-KLEEN) I �1 OI <br /> K AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br /> 5 GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are furry and accurately described above by the proper shipping name,and are classified.packaged, <br /> marked and labeledlplacarded,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 cergly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I eerily that the waste minimization statement identified in 40 CFR 26227(a)(it I am a large quantity generator)or(b)(dl am a small quantity generator)is M. <br /> Generaloes/Ofiemts Prnlad/Typed Name 5 nature Month Day Year <br /> a.,✓ '2IC� L <br /> International Shipments <br /> (_ ❑Impor to U.S. Expor from U.S. or of erltrylexil _ <br /> ransporter signature(for exports only): Date leaving U.S.: <br /> 17.TrdnsporterAdmaafedgnent of Receipt of Materials <br /> Trio 1 Printed? Name Signature Month Day Year <br /> O <br /> a <br /> QTrio iter rim Nell Signature Month Day Year <br /> K <br /> F- <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejed. L._J Full Pelectc,n <br /> Manifest Reference Number <br /> ?' ISo.ARemate Facility(or Generator) U.S EPA ID Number <br /> J <br /> U <br /> LL Farilily's Photo: <br /> w 18c.SignaWre of Alternate Facility(a Generator) Mrnln Day near <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 � 234. <br /> 20.Designated FacdhTy Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed7Typed Norma _ Sign _ Month Day Yzar <br /> EP F � � ouseditions are obsol D IGN 'ED FACILITY TO DE 1 ATION STATE(IF REQUIRED) <br />