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�• Sri rr qti�"''t <br /> SK SHI P4•$ -F""; -9°�t�"1 <br /> Please print or type.(Form designed for use on elite(12-pitch,, dwriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Res�tonse Phone a.Manifest Tracking Number <br /> (f,-✓11�-1:'t•? 3111 I t _ 1'7riy <br /> WASTE MANIFEST _yk;4 raft r., <br /> 5.Generator's Name and Mailing Address <br /> 10 0 <br /> /_) dLa <br /> SKS- <br /> eneit than madiog5n! iy Guard 401"p}raslriJ)ss) <br /> 580 GA; regie Strep, RECEIVE <br /> MANTECA CA 95-.^337-0000 <br /> Generator's Phone: 2101'3-239-919.1 1 <br /> 6.Trans orter 1 Company Name <br /> S EPA ID Nmber;YSTEMS, INC <br /> T� ?�UA 0i <br /> 8 a 2 <br /> 7.Transporter 2 Company Name ENVIR 01IAN'IN11 C= 21' M U- Number <br /> HEATH DFPARTX ENT <br /> 8.Designated Facility Name and Site Address CLEAN HARPORS 9AN JOSE LU`, U.S.EPA ID Number <br /> 1021 AERRYE SA ROAD <br /> Facility's Phone: 40R--441-0196�'! GAN JOSIE CA 95-433 C005949431 0 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> X ,. NA30 7, H AIZA DOU WASTE SOUD,, N.Q. ,S, r,� P D005 D0,06 DQ10 <br /> (LEAD. CHROMILIVD4 95'-�,s Iii <br /> D008 D@09 181 <br /> W 2 ,.,&.4L 11,11-N r CRA HAZARDOUS Wq;,ATF ,:�n►,..IUS, , � P 3�2 <br /> c� rA..B9h- ':PENT- -"CINTPMINr9TFP WI 14 OIL_), Nf>l ^4 <br /> Z � 4 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 116*11):&T 69-435758 1403400.3 <br /> C30` <br /> 1)ERG#171 <br /> 24 HR ErtEAGENC Y #1-600-468-1-760 (5K J T F I) <br /> AUT A-9 "AGENT-FOR" BY GEN Tri REIAIN \lei-,i' <br /> 15. GENERATOR'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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Gene``ratoes/Offeroes PrintedlTyped Name Signature. Month Day Year <br /> r 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> O Transporter 1 Printed/Typed Name Signature. Month Day Year <br /> IL <br /> aTransporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El ❑Type ype ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI p 1. 2. 3. 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 /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22 fev.3-05) Previous editions are obsolete. 7�} <br /> GENERATOR'S INITIAL COPY <br />