Laserfiche WebLink
SK SHIP# �&tll 11fill 111111 <br /> lease print or type.(Form designed for use on elite 12-2-Pitch) 0 0 5 3 2 9 4 7 6 5 KS <br /> ( p Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generator ID Number CAL00037"7.�II S 2.Pa 1 of 3. 4.Manifest Trackin Number <br /> WASTE MANIFEST g� � ��� ���� 0 0 5 3 9 4 7 6 {SKS <br /> ater's Name I u 3�nijD rAddress I Generator's Site Address(if different than mailing address) <br /> i � �f�t l..M3 r' t,�: Ai�i�f <br /> 8830 W ! 'sine Rd <br /> TRACY 2097-836-0965 CA 95304-9109 <br /> Generator's Phone: <br /> SYSTEMS, INC. U.S.EPA ID Number TXR0,: <br /> 0812055 <br /> I.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address —G <br /> 1021 BERRYESSA PCAD U.S.EPA ID Number <br /> 408-441-0962 SAN JOSE � CA 951:33 <br /> Facility's Phone: C"Dy=9x94:10 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> j !.C.Sn ;`s FAD), 9, PS I T f � ' <br /> l <br /> lt.I <br /> LU <br /> 3, <br /> 1. 4, <br /> 14.Special Handling Instructions and Additional information TED: —77M <br /> { <br /> U34171 <br /> 0-1- HR EMFhGE-NCY #1-800--468-1760 (SK / TFI) <br /> A-;UTH AS "AGNT_.FCR" BY SEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY I <br /> 15. GENERATOR'SIOFFEROR'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 Iabeledlpiacarded,and are in all respects in proper condition for transport according to applicable intemational 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)(if I am a large quantity generator or if I am a small quantity <br /> Zternati <br /> ratorslOfferor's Printed/Typed Name <br /> 1 { )( q ty generator)is true. <br /> Month Day Y,Yea <br /> .—I nal Shipments ( I <br /> ❑Import 10 U.S. ❑Export from U.S. Port of entrylexit: <br /> Frans signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> nc Tran rt 1 Printedlfyp erne Signature <br /> Month Day Year <br /> lransporter Printe!Typed Name Signature <br /> [e Month Day Year <br /> 13.Discrepancy <br /> 13a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> I Full Rejection <br /> I8b,Alternate Facility Manifest Reference Number; <br /> ty(or Generator) <br /> .i U.S.EPA ID Number <br /> Facility's Phone: <br /> ul 18c.Signature of Alternate Facility(or Generator) <br /> c Month Day Year <br /> CD <br /> t� 1F.Hazardous Waste Report Management Method Codes i.e.,codes for <br /> �J ( hazardous waste treatment,disposal,and I'eCycling systema) <br /> ILI t. }}} <br /> A/v/ 2. 3. 4 <br /> i <br /> 20.Designated Facilty Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except; n in Item 18a <br /> TrntedlTName Signature Mord�h 0 <br /> Q b 4 <br /> Eip 97qg, r�e4.,j19E '9,us editions are obsolete. DESIGNATED FACILITY TO DES ATION STATE(IF REQUIRED) <br />