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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) t.Generator ID Number Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.IAanifest Tracking Number WASTE MANIFEST 0�101�, / M-424-93011CHEMTREc 0 0 7 4 0 013 6 JJ K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) CERTAINTEED CORP 300 S.BECIWAN ROAD LODI,CA 03240 Generators Phon 6,Transporter 1 Company Name U.S.EPA ID Number FRBAWN ENVIRONMENTAL SERVICES INC CAR000171017 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENVIRONMENTAL SERVICES 14C 11AAD039322250 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE LLC U.S.EPA ID Number 1021BERRYESSA ROAD CAD059494310 SAN JOSE.CA 95133 Facility s Phone:408-4412 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WtNol. 0 1 Noo-RCRA Ffaardow Waste Sold(OUy DebrisxAbsotbart) S' MA /�O O P 223 ' ag W W 2. 3. 4. 14.Special Handling Instructions and Additional Wormation I'twxlers t0 be 4W batrltttd acid tm ppa. 9b1)CH 435474 -1"X irS` ERG*171 15. GEN ERATOR'S10FFEROR'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 labeled/placarded,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 dentified In 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorslORerors Printed(Typed Name Sig M/o�nthh Day Year � 16.International Shipments F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit Transporter signature for exports°nly): Date leaving U.S.: W 17.TransporterAdmoWAdgrnant of Receipt of Materials OTransputer 1 Printed/Typed Name Signature Month Day Year Transporter 2 Printed/Typed Name gnature n Month Day Year .'Liiiiife 5, 1— 18.Dicrepanuy �JOj/ Zd 18a.Discrepancy Indication Space El iDuaritty ❑Type El R.4,. ❑Partial Rejection ❑Foil Re)ection 18b.Alternate Reference Number.Facllity(or Generator) U.S.EPA ID Number V Facility's Phone: Ujj 18c.Signature of Alternate Facility(or Generator) Month Day Year Z W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) �^ 2. r3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the marrkst except as in Rom 18a PrintedlfgpeQJJame Signature Month Day Year ,v\ a r EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DE NATION STATE(IF REQUIRED)