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r .`. ` • it y`raA <br /> Please print or type.{Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB.No..2fl5a-Ql]39•f <br /> UNIFORM HAZARDOUS 1.Generator If]Number C91.'`008289-7 � 2.Page l of 3 _n'$i ' 'P � 4.man tfastTracktng Humber <br /> WASTE MANIFEST , 287 0 S�5,,'t <br /> 5.Ge retQrg Name Rod Mail ilg Address Generator's Site Address{f different than mailing address} <br /> l <br /> it;7j t C 95330-8'77 4 <br /> Generator's Phone: <br /> s.TT <br /> ,r rconyNap ?.,; ,► z i fiaC:,, U.S.EPA Ip Number T F?Cn� iZIf3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Food ity Name and Site Address QJ-.EAN �}t RECIRS SAN -10SE U.S.EPA 10 Number <br /> Wei K:Rf'LYESSA ROAD <br /> SAN JCSIL_ <br /> Facililys Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> RM and Packing Group{d any)) No, Type Quantity MNd. <br /> 1. ('if.,N I F1 f;P.7ilVLail}f7 W4 l I L I QG".9 Dill I.:r <br /> F r.rt •i+..+.I(. t of�f i t17• �t..:. Y G rL UT 1.014? r <br /> w <br /> �a <br /> 3. <br /> 4, <br /> 14,Special Handling Inshcbons and Additional Information <br /> �::'f ff -.r..ii _Pe ti r}' J.s}ll--A.t& S.�r�.0 ("ii f;�}) <br /> c 4.ti'r, �0' y-: :!'d '_art iR` F! �'•EV T'D RE. c;2�? LZfi•F:id}a�j LSI ff; G�13 R f.i f�� iia <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descn'bed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects In proper condition for transport according to applicable intemationaf and national govemmenlal regulations.If export shipment and I am Ne Primary <br /> Exporter,I certify that the corderds of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I Certify that the waste minimization statement Idengped in 40 CFR 262.27(a)(if I am a large quantity generatCr)or(b){f I am a small quantity generator)Is true. <br /> Generatorsl0ffaror's Printeffyped Name Signature 11 Month flay Year <br /> 18.IntemationaE Shipments ❑Import to U.S.` ❑Export from U.S. Port of entrylexit• <br /> M Transporter signature(for exports only): date leaving U.S.: <br /> � <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> �j Transporter 1 PrintedrTyped Name Signature Mont <br /> h Day Year <br /> per.. <br /> it <br /> QTransporter 2 PrintedlTyped Name Signartim ``— Month NY Year <br /> tr <br /> t— <br /> Ia.Discrepancy <br /> 18a,Discrepancy IndlCation Space ❑ Quantity 11 Type ❑Residue ❑Partial R.;.ti. ❑Full Re)ecticn <br /> Manifest Reference Number: <br /> lab.ARemate Facility(or Generator) U.S.EPA ID Number <br /> 3 <br /> ua Facility's Phone: <br /> LL[ 18c.Signature of Alternate Fadl ty(or Generator) Month Day Year <br /> 4 <br /> y <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> I T <br /> 1. 2. 4. <br /> 20.Designated Facility Owrier or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prink drTyped Name S6gnature Month Day Year <br /> EPA Four}87 22,(R•ev.f3 g5} Previous editions are obsolete. GENERATOR'S INtiIlAL COPY <br />