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L -0 0) <br /> D <br /> Cl) S;a SK SHIpYI re6Bci,4A5 <br /> O <br /> Form Approved.OMH No.2050-0035 <br /> rrt CO 61 <br /> O <br /> z Pli pnnl or lypa _ Z,1`19911M 3-�m�{g§��y qQ��% $ � 4.ManlreSl TsackVng Number ��� O IV m <br /> ^ r�¢nF T.i0 Namtar $lal7 p4l�ri� +6r(f Q 4 I--' 0 <br /> Vl UNIFORM HAZARDOUS i Al.i2fr�tQf�b��:7r'- 1- ar � <br /> D WASTE MANIFFST l5enemtors Siie Address til dlABrennhan mailing address) O <br /> 5.GenBrala's Name and Aaaniuo Atldress <br /> City Of Tracy (� <br /> D Bay de Svctr �0di8 N <br /> Z TRACY 209-A3i-41 EB (D <br /> GenemlNs Phcie <br /> u ' U.S.EPN v0 N�mhar (� <br /> l_r <br /> _r a T�ilti ' SYSTEMS INC: U O <br /> U S.EPA1D Number n D <br /> 7ryi5Dmrter?Of Vary Name I+tADa-: �• <br /> CLEAN HARBORS ENVIRGNt9ENTAL SVC INC. Oq CD <br /> U.S.EPA ID Num4er <br /> v"*Nam wdSite Addrem CLEAN HARBORS SAN TCiCf. � <br /> i@FI BERRYE5SA Ri - <br /> SAN JOSE F1 9S13;y CAIW 0; <br /> 408-441-0468 <br /> Faahty's Phare. U.UmI 3 <br /> Shipping 10-Containers It.Total 13-Waste Codes <br /> ya an.U.S DOT Ues nptwrt u rc nimp Proper_ ppmg Name.Hazard Class,ID Number, No. Type Quantity Wt,Nol. S <br /> HM P cki Group cif- 1 <br /> G 3Sc <br /> 1- � NON RCRA HAZARDOUS WASTE DM � nI <br /> >y <br /> 0 10IL, DIRT AND SAND) <br /> Q <br /> a O <br /> Cr u <br /> C <br /> � rn <br /> 0 <br /> rn <br /> r� <br /> (D <br /> 3 <br /> ay <br /> 7 <br /> (D <br /> rn <br /> r� <br /> Speeder Hanclina lnstru:dons and Addinoral Information TSD I G.T �fj.'J, 1 4 C 723?7 f - 0 <br /> O <br /> u_ authors <br /> 248 EmERGE,4CYOSOO-4613-1760_CH/SK/TFI--Contract retained by gpniii y00 <br /> O in t Tlsubstit'Atallt" y in name,a[d are cia55ified,packaged, V <br /> '5 GENERATOR'SIOFFERQR'S CERTIFICATION: I hereby declare that the contents of[his consignment are fully and accurately desenhed above b the proper shipp g A <br /> I� <br /> marked and labeled;piacarded,and are in all respects in proper condition fmrtranspod according to applicable international and national governmenlaV regulations If expnn shipment and I am the Pnmary V <br /> Eapode!I certify that the contents of[his consignment conform to the terms of the attached EPA Acknowledgment of Consent. to <br /> I rertiy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator}or(N(1I 3rh m_aVl quan6[y gar�eraforl is true, Month Day Year - Ln <br /> Signature ti _ -. N <br /> Geneatory0fterors PrintedrTyped Name I��: I� R •7" <br /> ED <br /> t6.tnlamelionai Shipments Import to U.S. ❑Export from U-5. Port of entryle t O <br /> I­ <br /> Transporter signature(for exports only) Date Veaving U.S L <br /> Ln <br /> 0:: 17.TrarWrWAdmowlerlgment mf Recelpi of Matenals month Day year fD <br /> w nature i < <br /> H Transpodar I Pnnled,Typed Name Sig _ <br /> IX <br /> O ` !? <br /> I Month Day 'leis <br /> Z Transporter 2 Prrnted'Typed Name Signature <br /> S <br /> O <br /> 78 DIsgepaincy C: <br /> ❑ <br /> F4 Re} <br /> Pa tial Reiaetion ❑ ectlonaj <br /> 18a DscrepancylndigronSpace ❑ Quantity ❑Type ❑Residue N <br /> 170 <br /> Manifest Reference Number: fD <br /> = <br /> 18b Allemate Facility dor Generalorl V.5 EPA ID Number tZ <br /> I� Q <br /> 1 (D <br /> 7 N <br /> Fane!);Pnoi Month Day Year 0`Q <br /> 18c,S;gnavc ofkicrnare Facility or Generator) v <br /> rrt <br /> N <br /> CL <br /> 4g Halardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> !. 2 3. �. p (DD <br /> (Q n <br /> O <br /> v s? <br /> '0 DeWaled III Owner or Operator:Cerllfieation of receipt of hazardous materials covered by the manifest except as noted in Item 138 Month bay Yea 0 3 <br /> �irltel�Typed Hie Signatureit <br /> 2 <br /> GENERATOR'S INITIAL CC o <br /> rm 87002_2IIRev.12-t7 ns are obsolete. <br /> cn i4S9b�6/1? 1 <br /> w <br /> (D 00 <br /> 0 <br /> - v <br /> 0 <br />