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Please print or type. (Form designed for use an elite 112-pitch) typewriterI i$054$333"02 SC PPW 7/12/201$ Form Approved, OMB No. 205x0039 <br /> UNIFORM HAZARDOUS 1. Generator ID tJrrMer 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAR 0 0 0 219 0 4 $ 2 $o0 4>�3 371s 1 6 8 FILE <br /> 6. Genera Name eM aiFng s Gene ators Site dress (if d8erent than making add psis) <br /> Target03i3 <br /> 4707 Pacific AveStu 4707 Pacific Ave <br /> Ge sl'tpnle: i - 228 ATIN re a Stlm*Wn.CA 95207 <br /> TIIIIraruporter I LOMIXIM/ Nama <br /> U.S. EPA ID Number <br /> Clean Harbors ErMronmentalSeritices, Ina <br /> 7. Tnmspoeer2 CoMAD 0 3 9 3 2 2 2 5 0 <br /> mpany Name U.S. EPAID Number <br /> S. Designated Facility Nam Site Address U.S. EPA ID Number <br /> Harbors San lose LLC <br /> 1021 Berrvessa Road CAD 0 5 9 4 9 4 310 <br /> San Jose. CA 95133 <br /> F s Phone: (4n91 4wli <br /> 90. 9b. U.S. DDT Desaiptlon (Inckrdkng Proper Shgpkg Name. Hazard Gass, ID Nurrbey <br /> HM and Packing Grow to any)) 10. Containers 11 . TDlal 12, Unit <br /> No. Type Ouantity W1_1V 13. Waste Codes <br /> • <br /> 1' UN1950. WASTE AEROSOLS, FLAMMABLE, (EACH NOT D001 D035 331 <br /> x EXCEEDING i L CAPACITY), 24 001 C F 0 0 '0 4P <br /> W <br /> 2' UNiB$7e WASTE ALCOHOLS, N.OwI (ALCOHOL, ETHANOL), 3. 0001 331 <br /> x PG 11 001 DF 0003 p <br /> 3' 11111993. WASTE FLAMMABLE LIQUIDS, N.OS., (ALCOHOL, <br /> X KEMNE19 3. PR II 001 C F 00022 p 0002 Ui54I D00 <br /> a. <br /> 0005 <br /> UN1263, WASTE PAINT RELATED MATERIAL, 3. PG it D001 D005 <br /> x 001 CF 0006 P <br /> 14, Speial Handkng Instructions andAddiBonal information 10008 83 2 <br /> 1 _Tar-Aero E Gft26 YZ30 4 rrss�55t7 <br /> 2 .Tar-Ethano1 ERGt127 1Zia ^ t� }- Otii20 � YI <br /> 3 _TAR 1L11Li_L ERG0128 1120 <br /> # - -Gens 12airin <br /> 18. GENERATOR'SDFFEROR'S CERTIFICATION: Ilrereby rledw that the contents Ur <br /> of Uis wreignrtrent are lY end aqua, y sal proper dvpackaged, <br /> marked and lawed(plecarded, and are in all respects in proper condition for transport accomkg to applicable International and national govemmenlal regi lel m. If export shrilment and I am the Primary <br /> Exporter, I oenity that tine contents of We consignment conform b the lem>s of 11w attained EPA Pdatnitedgrnant of Consent. <br /> I certify that tlne waste min, statement idenified in 40 CFR 26227(a) (ff I am a large quantity generator) or (b (8 a quantity generator) Is true. <br /> e s nn Name — a <br /> on y ear <br /> JOSEPH SATTERFlElD ON BEHALF T' <br /> 16, Infematiooal SNpmenls <br /> T signature for ❑ Import to U.S. ❑ Export from .S. Port ofentrylexg: <br /> 17. Transportereek nmMadgnat of Receipt of Materials Date Wift U.S.: <br /> Transporter I pri A I <br /> Sgradure ear <br /> Ic> y <br /> Transporter 2 Printedrryped Name <br /> nor re Day ear <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space ❑ ❑ Type ❑ Residue ❑ Parsai Rejecrion ❑ Ful Re*bw <br /> 186. AItemete FadSty (or Generator) ManiksI Reference Number: 111 11111 1 11 11 1 <br /> U.S. EPAID Number <br /> V <br /> W Fad s Phone: <br /> Q <br /> W 18c. 5(gnahve of Mamie III (or Generator) Month Day Year <br /> 2 <br /> Hazardous Waste Report Management Method Codes Q.e., codes for tauMous waste treatment, disposal, and recycfng systems) <br /> 1 Hi41 2 H141 3. 1414:1. 4. <br /> Hi41 <br /> 1 20. Designated Faalty ror Operator: t o pt Of hazardous materials covered by tine manifest except as no am 18a <br /> Pdnkdrryped Name Sionak" <br /> EPA Form 8700.22 (Rev. Previous its ate. DESIGNATED FACILITY TO DESTINATIONS <br /> Clean Hathers has the appropriate pennies for and will aeeeet the waste the &Water is shippinll (IF REQUIRED) <br />