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SHIP* RV -37505 <br />Pzase arint or Woe. !Form designed for use on elite 02=olloh) tvoewriter•) , <br />Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZRRUOUS <br />1. Generator ID Number i ,. <br />Ififitl�;.� r�rj!5;•s1 <br />2. Page of <br />r. � <br />. Eme�e c� Regpo a P�cuie� <br />'! "'i!"�-�-.W '�✓t� <br />4. Manifest Tra n Numh�ern° �`9 <br />1006,o SKS <br />MANIFEST <br />A <br />-d'. F�,�f' <br />- <br />5. Generator's Name and Mailin Address Generator's Site Address (if different than mailing address) <br />5. <br />149)-00 W, KiS'tway.. 12 <br />LOWGenerators <br />Phone: <br />6TT"WiipmRn a}: <br />FWSTEMS+ md, U.S. EPA ID Number XROWJ.a0812 5 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address CLEAN HARBORS SM JBBE U.S. EPA ID Number <br />10123 1 BERRYESSA ROAD <br />iyrFj"��.kf.,�°r e.•e.1}���*rk^� ���-���t���Wtr�€i,`r� �!z <br />Facility's Phone: <br />9a. <br />9h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />1. NON R€" I-1 HAZANDDIPS WASTE SOLIDS <br />r <br />Do", <br />P <br />2P2. <br />flZIS PETROLEUM HYDRUCARRON91 <br />6;z> <br />z <br />2. <br />c� <br />3. <br />4. <br />14. Special Handling Instructlons and Additional Information T1.0'.. 8,T 7781.5349 5 T be 05) 4 C,r 3�f <br />[, <br />r.�1.i��£ by S��.Ti,..ratvr confer.s e� elK y c341i�.�)Ot"3'' <br />01 initial to add or smhstitute ar➢£iition'al. � ap+yaor°tern ongni' er_ S hl <br />15. GENERATOR'SIOFFEROR°S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accrrrateiy described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (i€ I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator'slOfferor's Printed/Typed Name Signature Month Day Year <br />•e� .. -•� i • y c.' 0-1{ (A I8't? (�'�i .`dam ��'? .l�..r �n`..`,.'�-:�i7".��"'�»•'•..a,°q.w �f A1�_� ,� f`, _ <br />.-j <br />it <br />16. IrrIftatidnal Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U:S.: <br />W <br />17. TransporterAck6owledgment of Receipt of Materials <br />E <br />Transp rter 1 Printedl Name Sign turf" _, Month Day Year <br />J <br />QTranspo <br />a[.2 P intedlryped Name " Signature ��' 'Yom^ Month Day Year <br />^y a �6 <br />18. Discrepancy <br />189. Discrepancy Indicatlon Space ❑ Quantity ❑ Type [].Residua ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />- <br />Facility's Phone: <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ,. <br />LU <br />1. 4 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except,0 noted ialtem s18a , <br />P1ntedffyped Name J n Signature �; ' Month Day Year <br />r <br />f`r <br />'✓ f' <br />i-. ±¢7 .. r� G` M t `.'/ ( ' "•F „ f,,.r <br />~ <br />FPA <br />Fnrm 8700-22 fRev. 3-051 Previous editions are obsnfate. ' r 6F:gi Kr, A- OIn o4h611 ITY'86 rENERATOR <br />