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i FSK SH l Yui r '37P,861 P,86? Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST f. ]q 820 SKS 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Mal'. 6e,i:i iv Au Art Rd b CA 95215-�2M Generator's Phone: 09-931-7940 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number �^ "^7;7 JCS 8.Designated Facility Name and Site Address 1)!J HARBORS SAN JOSE, HC U.S.EPA ID Number t[2c1 BERRYESSA ROAD SAN JOSE , CA 95133 4(b8-°w41-tb962 CAM59494.310 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. I Z 2. w O 3. ,SAN J 20 0' s T 4. 14.Special Handling Instructions and Additional Information :4 HR EMERGEIVCY #1-800-468-1.760 (SAFETY-KL.EEN) 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement 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. Generator's/Offeror's Printed/Typed Name Signature Month Day Year J 16.International Shipments F- ❑Import to U.S. Export from U.S. Port of entry/exit: K Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials W Transporter 1 Printed/Typed Name Signature Month Day Year O CL J Y" Z Transporter 2 Printed/Typed NSignature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quant Type 1 Quantity ❑ yp El Residue El Rejection Fuil Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR