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Pham odor' nr hma !Porto decinned for ua nn elite /l7-niCh' Tree) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />0 0 0 a 5 7 <br />2. Page 1 cf <br />1 <br />3. Emergency Response Phone <br />(800) 483-3718 <br />4. Manliest Tracking Number <br />JJ K <br />WASTE MANIFEST C A H 1 1 1 <br />1001984869 <br />S. Generator's Name and Mailing Address Generator's Site Address (tdtferent than malling address) <br />5249 South Tracy Boulevard <br />County of San Joaqun - Tracy <br />1810 HazeltonAvenue Tracy, CA 95377 <br />Stockton, CA 95.201 <br />Generator's Phone: Attn: Kimbra Andrews <br />6. Transporter i Company Name <br />U.S. EPA ID Number <br />Clean Harbors Environmental Services, Inc. <br />M A D 0 3 9 3 2 2 <br />2 5 0 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />9 4 9 4 <br />3 1 0 <br />Clean Harbors San Jose LLC <br />C A D 0 5 <br />1021 Berryessa Road <br />San Jose, CA 95133 <br />Facility's Phone: <br />. <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />1 12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pecking Group if any)) <br />Quantity <br />WtNal. <br />c <br />1. <br />Mercury, 8, UN2809, PG III <br />0 0 1 <br />D F <br />0 0 0 8 <br />P <br />612 <br />z <br />z. <br />w <br />f'J <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />1.) CH240645—LP LCHG2 ERG# 172 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, <br />packaged, <br />marked and IabeleNpiacarded, and are In all respects in proper condition for transport according to applicable International and national governmental <br />regulators. If export shipment and I am the Primary <br />Exporter, I curtly that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br />I certify that the waste minimization statement Identified in 40 CFR 26227(a) (t I am a large quantitygenerator) or (b) (tl am a small quantity generator) is We. <br />Generator's/Ogemrs Printed/Typed Name 5ignature <br />Month <br />Day Year <br />Kim)oro Ati1a.� x�7s <br />° <br />16. International Shipments <br />❑Import to U.S. ❑5g1rtfrom U.S. Port ofentryledt <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter <br />i Pdnted7ryped NameSi r <br />Moniti <br />Da Year <br />g <br />Pdntedfryped Name Signature <br />Month <br />Day Year <br />ZTransporter <br />18. Discrepancy <br />I <br />ISO. Discrepancy Indication Space El Quantity [-1Type❑ Residue <br />❑ Portal Rejection Full Rejedionn <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />18c. Signature ofAhemate Facility(or Generator) <br />Month <br />Day Year <br />Q <br />2 <br />y10. <br />Hazardous Waste Report Management Method Codes (io., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. 3. <br />4. <br />20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />frnted/Tyyed Name Signature <br />Month <br />Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />