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SSL SK SHIP# 28 1 1 56863 IN III <br /> 009729310SK3 <br /> Please print or e, Form designed for use on elite(12•pfirh)typewriter. Form Approved.OMB Flo.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ro Number CALOW346561 2.Paq of 3.Emarr at1{y R Plf�r v 4.frwsnlhal Traeklrrg iVumher <br /> WASTE MANIFEST 005729810 SKS <br /> 5.Gjera)ors Name and Maling Address Generator's Sita Address(it 48ererA than mailing address) <br /> 4ti a <br /> 2150 W Charter Way <br /> STOCKTON CA 95206-1118 <br /> Generators Phone: 209-'941-4034 <br /> 6.T�d�rSsr�fonfoanti>Jiame SYSTEMS, INC. U.S.EPA ID Number TX ROOOO81205 <br /> 7.Transporter 2 Company Narm ��.�/s U.S.EPA I� D Nornbw <br /> ajmy--� <br /> B-Designated Fadity Nares and Site Address CLeM HARBORS r3M JOSE ] U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408-441-0962 CAD059494310 <br /> Fadtity's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalnars 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity WUVoI. <br /> 1, NON RCRA HAZARDOUS WASTE SOLIDS � DM �Co P 223 <br /> o (DEBRIS, PETROLEUM HYDROCARBONS; <br /> W P <br /> 53 <br /> 3. <br /> 4 <br /> 14.Speaal Handling Ins>r ONS and Aaditionat mbmation TSD:SJ 72388688 TC 10591 r� "CSG: <br /> 24 HR EMERGENCY #I 1500-46A-1760 (SK / TFI) �_I �O�Lkaa'!� <br /> RUTH AS AGENT—FOR BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOfMIM'S CERTIFICATWX I hereby dWam the(the contends of this consignment ars fully and accuratety desarW atxsve by the proper sNppirg name,and aro dassrFW.pstkagcr" <br /> marked and labeladlplaearded,and are in all respects In proper condition for transport according to appilceble International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that tha contents of this conslgnmeM oo*rm to the terms of the attaclxd E PA AdmtoMWgrmant of Consent. <br /> I r"rtity that the waste minimblion statement Idended in 40 CFR 26227(a)(if I am a Wge quantity genaafar)or(b)(il I am a small quan*gains la)is true, <br /> Gerrerators*ffewes PradedfTyped Narno SigYnatum Mmth Day Yaa; <br /> / llerlA�G D •r, C1 I <br /> 16.International Shipments <br /> ❑Import b U.S. ❑Export from U.S Pat o1 antrylexlt: _ <br /> = Transporter signature(for exports only): Date Waving U.S.: <br /> �uaa 17.Transporter Advrowledgment of Receipt d Materials <br /> TXQgp(rrter 1 Prin yped Name Sgnatura on14 Day Year <br /> �� 4[f` ;z-- <br /> CL <br /> Transpor�41rypod Name SQnaiwu lrwrrth Day rear <br /> f e. t� 1 <br /> 18.Discrepancy <br /> 1Be.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re)ection ❑Full R*coon <br /> Menftl Reference Number: <br /> r 184.Aftemato Fadiity tar Gensratory U.S.EPA ID Number <br /> J_ <br /> V <br /> Tai FaaliVz Phare: <br /> 18G Signature al A#ternals Faculty(or Generator) FAorafi Day Ybir <br /> a <br /> z <br /> 19.Hazardous Waste Report Ma,6vm Ukh)d Codes p.e.,codes fortbrardwas waste treatment.disposal,and maydi g systems) <br /> p 1 T <br /> 3. 4. <br /> zz- / e <br /> 20.0e51ti"FacilityOwner a lar receipt covered by the mantlestaxpfas noted <br /> ledll Name Mmth ow Year <br /> V <br /> EPfI oM7D4.2. 2't1lJVJ fgwseditlans a soiale. AE) SI <NATEDCILIT O ❑ STI TION STATE F Er❑U#RED) <br />