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State of Californio—Environmental Protection Agency Aillift <br />Form Approved.OMB No. 2050-0039 (Expires 9.30-9 77185-01 See Instructions on b page 6. Department of Toxic Su6stanc( <br />) <br />Please print er type. Form. designed for use on elite 11 typewriter. Sacramento, Coliforni <br />1. Generator's US EPA ID No. Manifest Document No. 2. Pag4, 1 Information in the shaded areas <br />UNIFORM HAZARDOUS L LIII <br />1 is not required by Federal law, <br />WASTE MANIFEST�-Anlb 61 "Y41 /I of <br />3. Generator's Name and Moiling Address f„ Ifs A. State Manifest Document Number <br />D G , 223149'41 <br />$ta <br />t to Generator's ID <br />h <br />to A. Generator's Phone jv/�(/� f w / -( �'J'�, - <br />1\ vvv <br />N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's 0[lieserved.1 <br />16' SAFETY—KLEEN SYSTEMS INC. TXR000050930 <br />O1. D.- Transporter's Phone $ (� 0 6,69-58401- <br />7. Transporter 2 Company Name 8. US EPA ID Number E...State Transporter's.ID'fReserved:J <br />aF. Transporter's Phone <br />�•V 9. Designated Facility Name and Site Address 05 014 4 10. US EPA ID Number G. StatEFcV4 94,310 ` <br />r..IZ CLEAN HARBORS SAN JOSE, LL <br />MZ 1021 BERRYESSA RD CAD059494310 H -Facility's Phone <br />�O SAN JOSE CA 95133 800 545-335$ <br />�VJ 12. Containers 13. Total 14. Unit <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) No. I Typo Quantify Wt/Vol I. Waste Number, <br />NON-RCRA HAZARDOUS WASTE LIQUID srgre 222-.. <br />t— OIL, WATER, SLUDGE( NOT DOT REGULATED) 0 TT j a EPA/Other <br />3 G � (� i1 fr <br />o E b. Stgre- <br />000 E <br />4 R 'EPA/Other <br />A <br />C. State, <br />o T <br />00 0 EPA/Other <br />-R <br />w d. State <br />f— <br />Z <br />ur <br />V EPA/Other <br />su <br />1. Additional Descnphons.for Ma1e6olslisted Above����� �} C� �j t K. Handling Codes for Wastes listed Above <br />� «11!l a. <br />14 b. <br />Ce s <br />C= 1% .c. d. <br />Q 111111 , , <br />Z 0' 15, Special Handling Instructions and Additional information MFST R/T#000000000 0-000-00 EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />Z SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />SKDOT# A: 3287 B: C: D: <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed,. <br />Vmarked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />J� 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 />n practicable and that I have selected the practicable method of treatment, storage, or dispos I currently available to me which minimizes the present and future threat to human heal <br />N and the environment; OR, if I am a small quantity generator, I have made a good faith eff t to minimize my waste generation and select the best waste management method that <br />ad <br />0 available to me and that I can afford. <br />O <br />} Printed/ p d NamSign Month Da Y <br />u G> d G <br />Z <br />sts <br />ujT 17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />w <br />p Printed/Typed Name I/ Signature Month Day Y <br />w <br />U-0 18. Trans ow <br />Transporter 2 Acknled ement all Recei t o Materials <br />0 T Printed/Typed Name Signature Month Day Y <br />W E <br />N R <br />V19. Discrepancy Indication Space <br />Z F 0%0% Aa N <br />A Py'A N <br />C <br />illi1 w <br />f 20. FacilityOwner or O erator Certification of recei t of hazardous materials covere /thisonifest ex as noted in Item 19. <br />T Prinfpd'/Typed Name % Signatur i Month Day Y <br />Y .l �� ,i.,�a-�.►-�/ mac- � <br />DO NOT WRITE BEXOW THIS <br />