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State <br />Form' <br />::.—Environmental-Protection Agency <br />: , OMB No. 2050-0039 (Expires 9-30-99) Alm See Instructions on baclami page 6. Deportment of Toxic Substances <br />Please <br />or type. Form designed for use on elite (12 pe rite 8 5 _ O1 Sacramento, California <br />'kJNIFORM HAZARDOUSh <br />WASTE MANIFEST <br />1. Generator's US EPA ID No. Manifest Document No. <br />V <br />Aki23 <br />2. Page 1 <br />of 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address ac' � <br />A. State Manifest Document Number 222790E <br />(� �-L <br />"l �o �} <br />B. StotelGenerator's ID <br />to <br />A. Generator's Phone (l 4 37 T 1! / qk � ( <br />C14 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. Stole Transporter', 1D [Reserved.] - <br />o <br />SAFETY-KLEEN SYSTEMS I.NC. T` R)('0153 C� <br />D. Transporter'sPhone <br />o <br />/� � <br />�, C9 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Ttansporter's ID [Res�ily d u <br />F. Transporter', Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />�V <br />Na <br />050144 <br />IC0$941010 <br />H. Facility's Phone <br />N� <br />CLEAN HARBORS SAN JOSE, LL <br />1021 BERRYESSA RDC'DP5R 19 31 <br />NO <br />n * T .. ,- <br />i <br />A �� <br />yU <br />+ +, `' ' <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. Unit` <br />No. <br />I Type <br />Quantity <br />Wt/Vol <br />I: Waste Number <br />Z <br />a <br />State <br />NON--RCRA HAZARDOUS WASTE LIQUID <br />Z' <br />j <br />/ �® <br />G <br />e-r <br />EPA/Othe <br />3 <br />G <br />OIL, WATER, SLUDGE( NOT DOT REGULATED) <br />l <br />o <br />E <br />N <br />b' <br />State <br />65 <br />E <br />EPA/Other <br />c <br />cv <br />'c <br />R <br />A <br />c. <br />stare <br />o <br />000 <br />T <br />O <br />EPA/Other <br />R <br />Ce <br />LU <br />d. <br />state <br />r <br />Z <br />EPA/Other <br />U <br />LU <br />H <br />Z <br />J. Additional Descriptions for Materials listed Above <br />K. Handling Codes for Wastes <br />... <br />listed Above <br />0a. <br />/ <br />�. 4 l%r <br />b. <br />V)Uj <br />509C. <br />d <br />Q <br />Z <br />0 <br />15. Special Handling Instructions and Additional Information <br />MFST R/T#000000000 0-000-00 <br />Z <br />EMERGE14CY RESP 300-463-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />W <br />SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the conten t 's onsig �rtient are hAlyland'dcc ra r'described above by prbper shipping name and Classified, pocked, <br />labeled, in in for transport highway according to app tcable international and national government regulations. <br />Umarked, <br />and and are all respects proper condition y <br />a_ <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical <br />I have the method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human heal <br />N <br />practicable and that selected practicable <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that <br />°c <br />Q} <br />available to me and that I can afford. <br />Print /Type Name <br />Signal a <br />Month Day } <br />U <br />Z r!9 <br />G <br />T <br />17. ra s or r Acknowled ement of Receipt of Materials <br />Printed/Typed Name <br />gna a <br />on Day } <br />WO <br />Ujw <br />Uj <br />R <br />w <br />S <br />LL.0 <br />18. Transporter 2 Acknowled ement+aWzecei t':of Materia s i' <br />Printed/Typed Name Signature Month Day } <br />0 <br />i <br />w <br />N <br />E <br />g <br />U <br />V <br />19. Dis o c di do oc <br />Z <br />A <br />omN <br />C <br />I <br />L <br />( <br />r\ <br />20. FacilityOwner or Operator Certification of receipt hazardous materials covered b t m fifes exce t oted in Item 19.. <br />T <br />Printed/Typed Names y. _ <br />Signature <br />Day } <br />rz � <br />/� 41e�� <br />/Month <br />DO NOT WRITE BE W THIS LINE. <br />