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See 1'nstructons on back of page b. Department of Toxic Substan' <br /> .AB' V2050-0039(Expires 9.30 99( h g p <br /> . type Form designed.for use on elite f7 2-pitch)yp` L 2. :; Sacramento,Califon' <br /> --"- -- -- -- 1. tor'sUSEPA ID No. Manifest Document,N 2. Page 1 Information in the shaded areo: <br /> UNIFORM HAZARDOUS j is not required by Federal law. <br /> WASTE MANIFEST g - rrx� of F• <br /> --3:-- StaT�'11AbanifestDocumentNumerGerierator-s-Name-amd-Maiiing-Address- T <br /> .A- f 2 <br /> _ �gc,.�J g�, B,-State Genarotor s ID- <br /> u7. .4-:Generctors Phore <br /> cY 5T"11-ansporFe"r 1`Cornp'any Name"- -- 6. USEPAID Number Ci State Transporter's ID'[Reserved.)- <br /> �t_��_t ., -- - �. -� ,r, f t •, V, Transporter's Phone - <br /> O SPiF Jr KIsEEN SYSTEMS TN111C, `t�5 1f,7 J . 't-, i <br /> O ^ e .. <br /> 1 <br /> ,�� 7-.Transporter 2 Crompany Nome--_- - <br /> B. US EPA ID Number - - E. Siete Transporler's ID[Reserve. <br /> D_ — `--- —. ------ <br /> 9. <br /> -_9. Designated Facility Name and Site Address 10. US EPA ID Number G: State Facility s ID - <br /> CLEAN HARBORS SAN JOSE, LL H: Facility s'Phone <br /> 4 �o . x.021 $E:RR ESS�A RD I� �U 9 �� - <br /> _. <br /> �tQ12. Containers. 13. Total 14, Unit <br /> U 11.. US DOT Description-(including-Proper Shipping Name,Hazard Class,and ID Number) No. - Type Quantity Wt/Vol L:Waste Number <br /> a <br /> ON E, m J C r•a °S EPA/Other <br /> G ?ii_.r WATE .,+CJ I tea{T I T REG L3�TED j � �z <br /> N .E 6 State <br /> o N <br /> �m E EPA <br /> /bib'er <br /> v R <br /> (V <br /> v A c State <br /> o T <br /> coo EPA/Qthef� <br /> R <br /> w d. State <br /> H <br /> Z <br /> 616 <br /> Lu > <br /> U <br /> Lu _ <br /> 1.`Additional"DescriptiogsJfor Materials Listed A6oJe K'Handling Codes for:Wastes'Listed Above <br /> :a; , 6. <br /> ]•' <br /> Uj <br /> c" d; <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 �,Sy-e <br /> Q a'ki' S s R/�T#C}C1�1S3Zi1��t00 Q-000-00 <br /> z <br /> EMERGENCY Y RESP iLT�-468--1'7�s0('2 ESR is UNDELIVERABLE; RETURN TO GENEL,AT0&. <br /> ut <br /> S ! CfRI AUTHORIZED TO ]RETAIN F.,ICEMSF ;'s�3�S' QUE;NT CARRIERS AS NEC '3SAAR.•1. <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare.that the conten s o t is co signment are fully an accura a y`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 applica6le international and national government regulations. <br /> If 1 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 hove.determined to be economical)y <br /> o- practicable and that I have selected the practicable method of treatment;storage,or disposal currently available to me which minimizes the present and future threat to human health <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 is <br /> � available to me and that I con,afford. <br /> O Print /Tyggd Name r. Signa ure .9 ' i F M h Day Y <br /> q ""1 `vont Year <br /> 7 5Y <br /> to T 17. Trans o&r Acknowled ement of Receipt of Materials <br /> Lu <br /> .N Printed/Typed Name Sign re • f'f lana Day Year <br /> s P <br /> 0 18. Trans iter 2 Acknowled ement of Recei_t of Materials40 <br /> 0 R Signature 1 Month Day Year <br /> T Printed/Typed Name 9 � / <br /> w E <br /> N R <br /> Q _ --. __._ .. ------- <br /> 19. <br /> _. _._ _ <br /> U 19. Discrepancy Indication Space — <br /> Z F <br /> _ A <br /> C - <br /> I <br /> L <br /> 1 20. facilityOwner or Operator Certification of receipt of hazardous materials.covered,b this,manifest except as noted in tem 19_ - -- <br /> T Printed/Typed Nome _Signature,- - Month Day Year <br /> or <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN,30 DAYS. <br /> DTSC 8022A(1/99) To: P.O. Box 400, Sacramento, CA 95812 0460 <br /> EPA 8700-22 <br />