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ssL SK SHIP# 2c5273323 111111111 110MMIM1111111111111 <br /> 0 0 6 5 2 0 5 1 7 S K 3 <br /> Please pnnt or type•(Form designed for use on elite(12-pitch) pewriter-) Form Approved-OMB No-2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Panne 4.Mantumber <br /> WASTE MANIFEST CALe0011a0247 1 1--600--461!-1760 10000517 SKS <br /> 5.Generator's Name and Malling Address Genamlors Site Address(if dlffwem then mailkyf address) <br /> American Honda Motor Co. <br /> 123 Val Derviin Pkwy <br /> STOCKTON CA 95206-4001 <br /> calors Phone: - e9-98 —.5 U.S.EPA 10 Number <br /> ransporfer t Company Name T X R000081205 <br /> SAFETY-KLEEN SYSTEMS INC <br /> 7.Transporler 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> a,besignated Fackity Name and Sita Address U.S.EPA ID Number <br /> CLEAN HARBORS SAN JOSE <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 CAD059494310 <br /> 408-441-0962 <br /> Facitit"5 Phonri <br /> ga. 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,tD Number, 10.Containers 11,Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> a X 1. NA3082, HAZARDOUS WASTE, LIQUID � DM P D00 ,E <br /> D018 22 <br /> N.O.S. , (LEAD, BENZENE), 9, P6 <br /> 2• err w - 3522 6 <br /> 3-D eat na� �� UAL �i/�.�i/LgNej 441V Adz �� �5 ! <br /> 4. <br /> F <br /> pecial Handling Inskuclions andAddltiooal Information TSD-.SJ 76672035 AM23152 CSG <br /> ' )ERG*171• 1,� -pp\0ON�7 <br /> 4 HR EMEl�GENCY #1-r800-468--1760 (CH / SK I TFI) <br /> 15. GENERATt7R`Sft7FFEROR'S CERTIFICATIGN: I hereby de0are Thal the oorrlents of Ns can&Ignmsnt are fufiy and accurately ascdhed shave by the proper shrprying name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects In proper condition 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity g6ereter)or(b)(111 am a small quantity generator)is true. <br /> Gwmratorsicfferors Printedflyped Name Signature Month Day Year <br /> J 1fi. arnational 5hiprnan s ❑ Port of entrylexit: <br /> F ❑Import to U.S. Export from U.S <br /> Z Tronsponer signature(fur exports only): Dale teav ng U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Malerials <br /> T' der der 1 Pnnted7T ame Signsbxa Mani Day Year <br /> � Transp r 2 F twill" ame 5igrrature Month Day Year <br /> tC•cS <br /> 18.Discrepancy <br /> 18a.Discrepancy rndlralion Spate ❑ Quantity Type ❑Reside P,61 Reaction ❑full R odion <br /> -PWO TG O� D�1 1 M r—voyn b ru r v�p To �lc'a� S �� <br /> 4&4W FOK riA9W ,-0# MatifestRef Number: <br /> 18b Alternate Facility(or Genomtor) -U.S.EPA TDNumber <br /> C] <br /> rat Facilitys Phone: <br /> W 18c Si nalure of Alternate facility(or Generator] Atanth Day Year <br /> d <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> c { Illelr z. a 11211 4 <br /> Designaled Facility Owner or Operatw Certification of receipt of hazardous materials covered by the manifest except as nae,/ Item 18a <br /> rrWwypd Signature Month Day Year <br /> , <br /> EPA Form 8700.22(Rev,3.05) Previous editions are obsolete. D SIG HATED FACILITY TO DESTIN N ATE (IF REQUIRED) <br /> 1)71659P-0/40566284 /SpIZ-j- <br />