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SK SHIP# 22990448 Form Approved.OMB No.2050-0039 lease print or type. 4.Manifest Tracking Number 1.Generator ID Number 2.Page of 3.Eme R e P o 007314155 O i ac� KS UNIFORM HAZARDOUS ' 1;� � 1� �� '" �� WASTE MANIFEST 5.Generators Name and Mailing Address Generator's Site;Address(if different than mailing address) cnerokee f=reight Lanes 5463 Cherokee Rd STUCK TON I Generators Phone: U.S.EPA ID Number T X 800008 yy0r.r 6.Tr_7�erfV-r`ffTW SYS E-ME9 INC p U.S.EPA ID Number IAD@3932,--.s_ 7.Transporter 2 Campan Name f��.i_.li� CI ~ RIre SVC INC. 8.Designated Facility Name and Site Address CLEAN HARBORS AN JOSE U.S.EPA ID Number W21 BERRYI SSO ROADSAN JOSE CA351 33 4013-441--0962 Facility's Phoney • .�- rbdU.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, ;10.Containers 11.Total 12.Unit 13.Waste Codes 9a. Quantity Wt.Nol. HMPackingGroup(if any)} No. Type 1 NONE NON RCRR HAZARDOUS WASTE LIQUIDS � DM � o F' 3�5� o r (BIES1_I._)Y N/A 2, NONE NON-RCRA HAZARDOUS JAS I E. SOL 1 DS Dim L)U R 352 UJI (DW S, DiKSEL CARBON RMD A64 3 s 4. °'z�.�� CSG S 14.Special Handling Instructions and Additional Information 'E!'S�.D p S�' ��5:31156805:3115680CH 38' l�4 1rMEfdGF.IdCYt 4f8��Z Ssr+ �N 4J F'UTF - Cantract retaired by generator confers a eney au�thora y nn initial transporter to add or substzt Ute adc(itiora trarl cart rs on Rnlsra �lr° behalf. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and ae.urately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for tran3port according to applicable internatio ial and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of tha attached EPA Acknowledgment of Cc nsent. 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 a small quantity generator)is true. Month Day Year Generators/Offerors Printed/Typed Name Signature 16.Interpational Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Date leaving U.S.: Transporter signature(for exports onIft W 17.Transporter Acknowledgment of Receipt of MaterialsUJI Month Day Year Tralnsporter 1 Printed/Typy Name Sig re �,e /, tr II t a .} '� '� f. ti'a+ Month Day Year z Transporter 2 Printed/Typed Name gnature 18.Discrepancy 18a.Discrepancy Indication Space ❑Residue ❑Partial Rejection ❑Full Rejection p y p ❑ Quantity ❑hype Manifest Reference Number: U.S.EPA ID Number 18b.Alternate Facility(or Generator) J U I Facility's Phone: Month Day Year US 18c.Signature of Alternate Facility(or Generator) Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2. 3. 4. 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year Printed/Typed Name Signature I I I EP Fat ti 00 2 (Re 1 g is a tigr�s r o e GENERATOR'S INITIAL COPY