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Poe <br />SSL SK SHIP# 231050382 <br />ase print or type. <br />1. Generator ID Number <br />UNIFORM 14AZARDOUS <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address <br />149610 WnDelta HiighwayR1s2�rt <br />LORI 209-R83--1589 <br />Generators Phone: <br />s. Tran PFTY Y. SYSTEEM�S INC <br />CAL000426023 <br />CA <br />11111ILIIIIC1111 1Illil1l111 <br />0074 <br />Form Approved. OMB No. 2050-0039 <br />1�8 g SKS <br />[if different than mailing address) <br />CLEAN HARBORS ENV SVC I <br />8. Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE <br />1021 BERRYESSA ROAD CA 95133 <br />SAN JOSE <br />408-441-0962 <br />on=Hazard Class, ID Number, <br />SOLIDS <br />CARBOrtS <br />z 2. <br />LILL0 <br />EPAID <br />10.Containers 11. Total <br />No. Type Quantity <br />DM 9-'50 <br />TXR0010111181205 <br />MIAD039322250 <br />CAD059494310 <br />12. Unit 13. Waste Codes <br />Wt.Nol. <br />P 223 <br />82778554 ST4305t7; CSG: <br />l4. Special Handling Instructions and Additional information TSD'- e.�J tor confers a envy authori y <br />ti24H EMERSENCY#800-468-1760-CH/SK/TFI-Contract retained Y ackaed, <br />er shipping name, and are classified, Q 9livable lly and accu and nationl regulations. if export shipment and I am the PrimaryERTIFICATION: I hereby declare that the contents of this consignment are fully and accuretefy descria proparked and Iabeledlplacarded, and are in all respects in proper condition for transport according to app Gl r is true.Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of consent.MoDa Year <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity S ner ator))oor (b)) (if I am a small )Generator roesPrintedffyped a/ / /,.�:, xp..6. iemational Shipments S <br />Transporter si_nt,rpffor exports only): <br />17. TranslprorAcknowledgment of Receipt of Materials <br />11, <br />18. Discrepancy❑ Partial Rejection <br />iBa. Discrepancy Indication Space LJ Quantity <br />❑ Type ❑Residue <br />Manifest <br />1 Bb. Alternate Facility (or Generator) <br />C) <br />rat Facility's Phone: <br />W 1 Sc. Signature of Alternate Facility (or Generator) <br />a <br />z <br />N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling <br />1� l Lk 1 2. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the Manifest ?e t <br />Pr nked ed me b Q �� <br />EPA <br />� 83�����R� V. 12-17) editions are obsolete. <br />Number <br />noted in Item 188 <br />DESIGNATED FACILITY <br />D� <br />Full Rejection <br />TMAT`IIFEST SYSTEM <br />