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State of Colifornic—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on ba page 6. Department of Toxic Substance: <br />Please print or Noe. Form designed for use on elite (12 pewry'tar. Q _ n Sacramento, Californic <br />O <br />W) <br />N <br />W) <br />00 <br />W-0, <br />YV <br />�Q <br />"Z - <br />/\MO <br />C A <br />CI\JU <br />Z <br />. z <br />3 <br />at <br />w <br />t— <br />Z <br />w <br />V <br />w <br />N <br />0 <br />h <br />w <br />Q <br />Z <br />0 <br />a <br />Z <br />w <br />V <br />J <br />a <br />in <br />Cid <br />L <br />U <br />Z <br />w <br />0 <br />Ix <br />w <br />I <br />w <br />14- <br />0 0 <br />LU <br />. N <br />Q <br />U <br />f� <br />DO NOT WRITE BELO4jKTHIS LINE. <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />Y1 <br />is not required by Federal law. <br />WASTE MANIFEST <br />qAO92Pq2T6j%2 <br />�A.: <br />of 1 <br />3. Generator's Nome and Mailing Address <br />MARTIN BROWER <br />Stofe'Monifest'Doeument-Number rr�� <br />�G324Grr� <br />1 <br />4704 FITE CT <br />— <br />B: State Generotor's ID <br />.6TerIIr KT qua t I CA 95205 <br />5. Transporter 1 Company ame 946 3948 6. US EPA ID Number <br />C. State Transporter s ID [Reserved.) <br />D. Transporter's Phone <br />SAFETY-XLEEN SYSTEMS INC. I T 0 0 011 30 1 1 1 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. `.State Transporter's tD,(Rese 6 6— <br />'F,:Tioneporter'i Phone. <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />Gc, State Facility's ID <br />050144 <br />— <br />H Focilitys'Phone <br />CLEAN HARBORS SAN JOSE, LL <br />1021 BERRYESSA RD C 0 91414? 1 <br />. <br />w — <br />J J 1E. CA 95t,33 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />nit <br />No <br />Te <br />yp <br />Quantity <br />WI/Vol <br />I. Waste,Number. <br />a, <br />State' — <br />NON-RCRA HAZARDOUS WASTE LIQUID <br />EPA/Othe — <br />G <br />OIL,WATER,SLUDGE(NOT DOT REGULATED) <br />AA <br />TT <br />G <br />E <br />N <br />6— <br />' State <br />E <br />EPA/Other <br />R <br />-7 <br />T <br />c, <br />State <br />0 <br />EPA/Other — <br />R <br />— <br />d. <br />State <br />EPA/Other <br />1 Additional Descriptions for Materials Listed Above 9/ <br />K. HandlingCodes r Wastes <br />Listed Above <br />b. <br />r <br />c. <br />15. Special Handling Instructions and Additional Information <br />MFST R/T#103610050 0002-8013-01 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR <br />SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the conte=5QcTr*gnrAra are fully 12Ac7rat4escribed above by prc e; shipping name and ar iassified, packed <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to opp -cable international and national government regulations. <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 />practicable and that Rove selected the proctico6le method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human keol <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to inimize my waste generation and select the best waste management method that <br />available to me and that I can afford. <br />Printed/Typed Name <br />Si nat a <br />Month Day 1 <br />> to <br />o <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Mat 'als <br />R <br />APrinted/Typed <br />Name <br />Signature <br />nth Day 1 <br />N <br />S <br />)Q�004y& <br />I <br />P <br />0 <br />18. Transporter 2 Acknowled ement o ecei of aterials _ <br />R <br />T <br />Printed/Typed Nome <br />Signature <br />Month Day 1 <br />E <br />R <br />_ <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />— <br />( <br />20. Facility Owner or Operator Certification of rete- t of hazardous materials covered by thi o ' t qftept as noted in Item 19. — <br />T <br />Printed/Typed Name <br />Signature r <br />Month Day r <br />DO NOT WRITE BELO4jKTHIS LINE. <br />