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Su 5H I P# ?25560914 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Cr`n rUrtrl 81 uu-LL tKev. 3-05J Previous aarcions are oosoiete. <br />'DESIGNATED F7)T"Y 79TIN4-Ci(5N ST-TTE (IMEOUIRED) <br />Page 24 <br />pprove . o. 5 -0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Pagl of 3. Emergency Response Phone est Tracking Number <br />WASTE MANIFEST _ SKS <br />MU <br />5, Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />i,a:Qr, 7sort, LLC <br />14900 1W I•i3gYiway 12 <br />r to Zrt <br />5J`242-000E%T <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SPIFFTV--Vt FEN SYSTEMS INC <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />t; t Ra ENVIRONMENTAL SVC INC. MAD0393a2250 <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />CLEAN HARBORS SAN JOSE <br />1021 BERRYESSA ROAD <br />SAN JOSE r -P 'x71 77 <br />CAD059494 31 fA <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />wt./vol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />NON RCRA HA7ARDOUS WASTE SIAL_ s DS <br />.y <br />IDEBRIS, PETROLEUM HYT'R66PRON.131 <br />w <br />' <br />z <br />2. <br />ev <br />c9 <br />3. <br />3 <br />4. <br />14. Special Handling Instructions and Additional informationTSD T <br />-,4 HR EMERs NCY #1-8112110-468-1715,113 (CH i S TVI <br />zE iTr-t ,C ceQ C, C'IN, IT— F f1r - tI n V f,- r-7 Pi TT t f C iT1 <br />15. GENERATOR'S10FFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper s ippirng name. and are classified, packaged, <br />marked and iabeledlplacarded, and are in ail respects in proper condition for transport according to applicable international and national governmental regutations. 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b if I am S small quantity generator) is true. <br />Genera r's,'Oiferors Print ypeda Signature Moth Da Year <br />j <br />16. Interna onal Shipments <br />Import to U.S ❑ Export from U.5 Pori of entryrexit, <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />E <br />17- Transporter Acknowledgment of Receipt of Materials <br />ir <br />TrIpolter 1 PrintecIff Name Signatu Month Day Yeal, <br />O <br />CL/ <br />en <br />QTransporter <br />2 Prin Iryp ME Signature Month Day Year <br />18. Discrepancy <br />18a- Discrepancy Indication Space ❑ QuantityT Residue 1 ❑ Ful€ Rejection <br />❑ Type ❑ ❑Pallial Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA C Number <br />U <br />L" <br />Facility's Phnne: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1. / <br />/- V/ — I <br />2. <br />3, 4. <br />1 <br />— <br />20. Designated Facility wner or Operator: Certification of receipt of zardous materials covere y the manifest except V noted in m a <br />Printed ed Name Signature Month Day Year <br />Cr`n rUrtrl 81 uu-LL tKev. 3-05J Previous aarcions are oosoiete. <br />'DESIGNATED F7)T"Y 79TIN4-Ci(5N ST-TTE (IMEOUIRED) <br />Page 24 <br />