Laserfiche WebLink
State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30.99) 18 5 —01 <br />Please print or type. form designed for use on elite (12pitchrifer. <br />O <br />h <br />h <br />n <br />N <br />h <br />0 <br />NC? <br />J <br />C"V <br />00 <br />rQ <br />` Z <br />NW <br />�O <br />�V <br />Z <br />3 <br />N <br />O <br />00 <br />00 <br />-t <br />N <br />6 <br />O <br />00 <br />oc <br />w <br />Z <br />w <br />V <br />N <br />O <br />V) <br />Uj <br />See Instructions on back of pa Department of Toxic Substances Control <br />Sacramento, California <br />DO NOT WRITE BELOHIS LINE. <br />22A (1199) White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 80 <br />EPA 87022A To: P.O. Box 3000, Sacramento, CA 95812 <br />1 . Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUSr ! <br />WASTE MANIFEST c (�J S10 -13� <br />1 <br />of <br />is not required by Federal low. <br />3. Generator's Name and Mailing Address r i <br />S�u��` I¢I <br />' A. State Manifest Document Number <br />222.75922 <br />pqo� JAlig�.ft1P4kI <br />B. State Generator's ID <br />vPvv e <br />A. Generator's Phonerl <br />j )q - S'yi1� <br />5. Transporter 1 Company Name 6, US EPA ID Number <br />C. State Transporters ID [Reserved.) <br />SAFETY—KLEEN SYSTEMS INC. TXROOOC�50930 <br />D. Trans 800 669-5840 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.) <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Fa'ID <br />s <br />CA Of9494�10 <br />050144 <br />CLEAN HARBORS SAN JOSE, LL C`ADOS9494310 <br />1021 BERRYESSA RD <br />H. Facility's Phone <br />SAN JOSE CA 95133 I I I I I I I I I i <br />800 545-3358 <br />11. US DOT Description lincluding Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />No. <br />Type <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />' Stale... <br />a. <br />NON—RCRA HAZARDOUS WASTE LIQUID <br />222 <br />EPA/Other <br />OIL, WATER, SLUDGE( NOT DOT REGULATED) <br />TT <br />G <br />G <br />E <br />b <br />State <br />N <br />E <br />EPA/Other <br />R <br />A <br />State <br />T <br />c <br />0 <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Addilional Descriptions for Materials Listed'Above <br />K. Handling Codes For Wastes Listed Above <br />o, b <br />14 <br />15. Special Handling Instructions anqAddi nal Information <br />MFST R/T#000000000 0-000-00 <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 />SKDOT4A <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 />in for transport by highway according to applicable international and national government regulations. <br />marked, and labeled, and are in all respects proper condition <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 economica11 <br />treatment, or disposal currently available to me which minimizes the present and future threat to human health <br />practicable and that I hove selected the practicable method of storage, <br />and the environment; OR, if I am a small quantity generator, I have made a good Faith effort to minimize my waste generatio and the best waste management method that is <br />available to me and that I can afford. 717 <br />Pri /Typed Name \ IL' \I1� Ej-1 X14 <br />Si e _ <br />E <br />Mont Dogs QYea <br />[`- <br />T <br />17. Transporter 1 Acknowledgement of Receipt of MoWiols <br />pPrinted/Typed <br />N <br />Name <br />Signature <br />Month Day Ye <br />o <br />S <br />6/ (/// <br />P <br />1 B. Transporter 2 Acknowle mens of Recei t of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />[ <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b th s ni sr e t a Item 19. <br />T <br />Printed/T ped Name /' <br />Signature <br />r Month Day Year <br />DO NOT WRITE BELOHIS LINE. <br />22A (1199) White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 80 <br />EPA 87022A To: P.O. Box 3000, Sacramento, CA 95812 <br />