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<br /> Please print or type. Form Approved. OMB No, 2050-0039
<br /> UNIFORM HAZARDOUS ll , Generatorl( Number C(yt_17J44t1t ` ritb 2. Paget of 3• Eme�rg��.Gy Ryr�SpoAse h iG 4. Manifest Tracking Number
<br /> WASTE MANIFEST 1 55 uuJJ ii ((�9 t a F• SKS
<br /> 5, Generator's Name and Mailing Address Generator's Site Address (if different then mailing address)
<br /> Mao Irarl Algid Iylet: aa !
<br /> 1015 Navy Dr
<br /> SITICKTON CA arr5r�tpf ,W1178
<br /> t+? 94041932t� 1107
<br /> Generatporp'rs�ePhone:rr��an��rq@
<br /> G. Trr�p�if' E. rW YiL,"tt [q wi'�S7T .( r�E; U.S. EPA ID Number t 5
<br /> 41 ! 3( IS �i181 1. .u ..S
<br /> 7. Transporter 2 Company Name U.S. EPA ID Number
<br /> CLEAN 14ARBOR'.7 ENVIRONMENTAL SVi., I ffalaIAAM9322250
<br /> ik..
<br /> 8. Designeled Facility Name and Site Address CLEAN HARBEIR i 11AN JOSE U•S. EPA ID Number
<br /> 1, 021 k1�; RRYE" 3F1 ROAD i
<br /> SAN N tiTf. S p fit S 95133
<br /> 3
<br /> Facilily+s Phone:
<br /> ga. 9b: U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit `
<br /> 13. Waste Codes
<br /> HM and Packing Group (If any)) No. Type Quan&, WI,Nol.
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<br /> NON RUM 1a�17t-I €�:f1OU S . 6J'A9 )'I 0101AIDS � CV j ',) (. . f i' a^ t
<br /> ( DEBRIS , PETROLEUM IttymbrARBON83UJ
<br /> 2.
<br /> 3.
<br /> 4.
<br /> 14, Special Handling Instructions and Additional Information 4121111) 4 83 8 121 ,' f-i011Z 11 F1h.ki:l�f 1 1 I f G 0
<br /> 2 14114 _•, 1 '76�r�M.I.�H118Ki"IFI 120lit t^ of t eta :fble; d by pleierat ar. r: ft ,Pfers all rli_' yi - iddidt �� t3r74 % )
<br /> oili initial �tr"am ctr er to .cxcld or sUbS ; a. tute adda, tiall l tPP3101 pn ', tQrS urs Ia �� haX 'Eo
<br /> 15, GENERATOR'SfOFFEROR'S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged,
<br /> marked and labeled/placarded, and are In all respects In proper•t;ondilion 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 EPAAcknowiedgment of Consent,
<br /> I certify thafihe waste minimization statement Identified in 40 CFR 26227(s) (if I am a large quantity generator) or, b) (if I am a small quantity generator) is true,
<br /> General• r'slOffeto�s PfrinledffyRe<d Name Sign�lofe 5 P) Month Day Yeayr
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<br /> 16. Internal final Shipments
<br /> F] import Import to •U. . ❑ Export from U.S. Port of entry/exit:
<br /> z Transporter signature (for exports only): Dale leaving U•S,:
<br /> iY 17. Tragsporterftnowledgment of Receipt of Materials
<br /> Tran Iporier 1 Printed/Typed ame ti� Signature' 7. ,��f ff `r,-'' Month ,• .Dq}y spar
<br /> O 1 �.,. . C � i 1 «� \ d 1 A !�j � !� Ir ►ti/ rl f . � . _ i!r.y.. , -,e...� �L . %�
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<br /> Transporter. 2 Prints [Typed Name Signature f, ' r ' Month Day Year
<br /> 18• Discrepancy
<br /> 18a. Discrepancy Indication Space Ouantily ❑ Type ❑ ResidueRejection Full Rel
<br /> ection
<br /> Manifest Reference Number.
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<br /> 18b, Alternate Facility (or Generator) U .S. EPA ID Number
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<br /> u�. Facility's Phone:
<br /> Li 18c. Signature ofAllernale Facility (or Generator) Month Day Year
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<br /> 19. Hazardous Waste Report Management Method Codes (i,e., codes for hazardous waste treatment, disposal, and recycling systems)
<br /> 0 1 . 2. 3. 4.
<br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1811
<br /> Prinled(Typed Name Signature Month Day Year
<br /> „h.
<br /> EPA Fo 8 ,pQ�2 dR v. 9, � � P evious editions are obsolete. GENERATOR'S INITIAL COPY
<br /> 1 ) 1�SEly� � 1. t�� .z:�,3 � i
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