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SK Si i I P# 231160742 <br /> Please print or type. Form Approved.OMB No 2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emer enc Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CACIP630524B5 i I— - -4,, --A760 <br /> WASTE MANIFEST SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Mascinite Corporation <br /> 30 W &—Otts Cave <br /> (-r3(; DN C{� 9�1�'03 0fd0 i <br /> Generators Phone: 209-948-0637 <br /> 6.Transppner 10 N U.S.EPA 10 Number , <br /> tnnr,1 `—tSl EI SYSTEMS INC <br /> 7-Transporter 2 Company Name U S.EPA ID Number <br /> C,'LEAN HARBORS ENW .alit', TNIiNf�Df�3"�3�_:'_r50 <br /> 8-Designated Facility Name and Site Address CLEAN HARBORS $AN JU SE U.S.EPA ID Number <br /> 101.1 BERRY!:SSA ROAD <br /> SAN JOSE: , CA 95133 GAl]05 sk'343118 <br /> Facility's Phone: <br /> 9a go.U.S.DOT Description(including Proper Shipping Name,Hazard ClasS,ID Number, 10.Containers11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Vol, <br /> ! —RCRA HAZARDOUS WASTE, SOLIDS JR1 <br /> F- (SAWDUST AND GLUE), NM <br /> z. IVBIVE:t N(':IV—R FTA HAZARDOUS WAST, SOLt DS C1 <br /> 3 11M NON RCKA HAZPRD011S WASTE SOLTD5, P 35cc^_ <br /> a NfIRE NLiiri—Rt A HAZARDOUS WASTE, S;JI_.]DS NONE <br /> (MLIGA QUARTZ), WM <br /> 14 Special Handling instructions and Additional Information 7� ( q " ?,� <br /> TEM:w7.} 82894277 �rtf^3�f�r 7j() <br /> �4H EMERGENCwY#800- 468--'1760--•CH/SK/TFf--Cantra t retained by generator r_�tnfr:-F � ,:�ncy atutfisora <br /> ,i ti s u l - 11 <br /> 15. GENERATOR'S1OFFEROR'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 labeledlplacarded.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 EPAAcknowledgment 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 sm II quantity generator)is true, <br /> GeneratorslOfferor's PrintedlTyped Name Signature r Month pay Year <br /> 16.International Shipments <br /> 1 1:1Import 10 U S. ❑Export from U.S. Po entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI Month Da Year <br /> tS�rter <br /> Trar1 PrimadlTyped Name Signature y <br /> to ' Month Day Year <br /> M Transporter 2 PtImedlTyped Name Signature <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> } 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> F <br /> V <br /> W Facility's Phone: <br /> w 18c.Slgnalure of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 2 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLj C1 1 2. 3 4. <br /> 20-Designaled Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest excepl as noted in Item 18a <br /> Printedfryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. ff NERATOR'S INITIAL COPY <br /> .. 8'781157/1963346 08837487/200042 <br />