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SK S 217260057 <br />Please print or Woe. (Farm desioned for use on elite (12-Ditchl hroewritec) <br />004764824SKS <br />Form Approved. OMB No. 2050.0039 <br />EPA Form87p022(Hev.'MYFYeviouSepmon!pDDsolele. - UrotulvHICUrrynurrI x„ <br />UNIFORM HAZARDOUS <br />1, Generator ID Number CALO1003887F, .. <br />2. Page j of <br />3. Emergency P-4vise Phonic <br />4. Manifest Tracking Number �/ <br />WASTE MANIFEST <br />004764824 SKS <br />5, GeneraladNanie find �t rgsr�ipp Generator's Site Address (if different than mailing address) <br />i <br />2979 Auto enteerr Cir <br />STnrKTON CA 95212-28: t' <br />209-662-6400 <br />Genarara s Phone: <br />s.Tagperl¢IGcapesyZslnl, SYSTEMS, INC. U.S. EPA ID Number T':90001381 Q.5 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address - l U.S. EPA ID Number <br />10221 BERRYESSA ROAD <br />SAN JOSE , CA 95133 <br />408-441-09b2 CA[7059494310 <br />Fa 's Phone: <br />ga. <br />9b. U.S. DOT Description [etl ening Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12 Unf <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Paddrig Group (t any)) <br />Qua" <br />WILM. <br />1. 18ShRBENTS CONTAMINATED WITH OIL>, N%A <br />UM <br />0 <br />O <br />z <br />z <br />Lu <br />r'7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information a . • a 1315•.rr.. ' - <br />1 50 3 a 2 <br />24 HR EMERGENCY #1-600-468-1760 (SK / TFI) <br />RUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY' <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuly end accurately, described above by she proper shipping name. ant are classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper andibon for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter. I oertily that the contents of this consgrhmem conform to the tennis of the attached EPAAcknovAedgment or Consent <br />I certify Nat dhe waste minimization statement identified in 40 CFR 2622T(a) (f I am a large quantity generator) or (b) (if I am a small quanuty generator) is true. <br />Genermols'Oferor's Pnnted'Typed Name � nature Month Day Year <br />Fes.; i V <br />16. liternational Shipments <br />❑ Import to U.S. Export ftim U.S. Port of entiyrexf: ____ <br />= <br />Transporter signature (for exports of Date leaving U.S.: <br />W <br />17. Trampkier Aduiowledgment of Receipt of Matenats - <br />cc <br />Tran r PnntedrT ped N Signature Month Day Year <br />O <br />a <br />C <br />QT <br />rter 2 Pnnledliyped Name nature Month Day Year <br />lX <br />I.- <br />& Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouanut ElType ❑ Residue ❑ Partial Rejection El Full Rejection <br />Y 1 <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />tai <br />Fa6lgs Phone: <br />Q18c, <br />W <br />Signature of Afterade Facility (or Generator) <br />Month Day Yam <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycWg systems) <br />LU <br />1. / <br />2. <br />20. Designated Facility Ovvner or Operator Certification of receipt of hazmdous materials avmad by the manifest except as noted in Item 18a <br />1 <br />Prmled/T Name SkpaW Monty Day Year <br />ON <br />vI <br />EPA Form87p022(Hev.'MYFYeviouSepmon!pDDsolele. - UrotulvHICUrrynurrI x„ <br />