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print or type, -Z2 "" ,, _ Form Approved.OMB No.2050 0039 <br /> UNIFORM HAZARDOUti 1,Generator 10 q6mlier E4Manifernl00014636f Tracking Numbo, 1' <br /> WASTE MANIFEST <br /> 672.4840 <br /> 5.Genemlor's Name and MoilingAddrass eneralot s SiloAdtlress(if different Than madmg adtlrass) <br /> cl%ca Air, Zjystsifls 111c! <br /> 2Y4 27th St 14 <br /> SACRAMENTO ' <br /> CA 95816-3201 <br /> 916-444-234k.1 I <br /> Generator's Phone: <br /> 6.Tiq 1-1- �r�L,�i�S;,><deSYS'MW'i iI�14:. U.S.EPAIDhumtrar T.YR000061203 <br /> 7.Trans oder2 Compan Name �U,S.EPA ID Number <br /> I:L, F1N NP1Ft tUt Lr r:NVI.F� NI C'IV7%1L SVC INC. <br /> 8.Designated Fatality Name and Silo Address {CHARBOR SAN JOSE U.S,EPA ID Number <br /> i fA I BERRYESSA ROAD <br /> SAV JOSE p CA 931,33 <br /> 408-441--M62 <br /> Facility's Phone: <br /> ga. 9b:u;s,OOT Description(Including'Prope Shi,ping Nome,'Haiard Class,10 Number; _116.Containers 11,Total 12.Unit }3.Waslo Godes <br /> HM and Packing Group(if any)) _ No, ,TYp/s Quantity "'IV01: <br /> i. NON RCRA MA :A( # 3 (Ci GtAG'M SOLIDS, Lh� P 2213 <br /> 2. <br /> r <br /> TZ''r <br /> AC <br /> 4. <br /> 14,Special Handling Instructions and Additional <br /> Into mail n t N A x �� �� CSGj f <br /> 24!-! EIIIERCENCY#8100-468 R 4i�r l^l1 F'�ITC~I .t.txn r� c t retains �y ggnerar, C,nferl•r's acte ic�� , tai i�i���X 47 <br /> U1 initial i,ansurt t� add drSubstitut.it: addxt onal `o <br /> t^abb <br /> nirarlws-on u- uratbr,lq heKalf. <br /> 15, GENERATQR'SlDFFERDR'S CERTIfiCAT10 i hereby declare ihatihe contentsof(his consignment pro dWlyand accurately described above by the propel shipping name,and are classified,packaged, <br /> marked and labeledlpiacarded,and ore in all re pect$a In proper condition for.lransport according tQ+applicable Intematfonal and national govel`nmental regulations:If export shipment and I em the Primary <br /> Exporter,I certify that the contopis of this const omer�l conform to.lhe terms of the ailachad EPAAi knowledgmant of Con eA <br /> rtify that the wasle.minimization statement f entlOd in 40 011282,27(a)(If i am a large qual" generator)or )(if a a small quantity generator)Is true. <br /> enerat 's/OfferoYs PriritedfTypetl Name Signature Month Day Year <br /> r; <br /> 16,International Shipments <br /> f. ❑Imporf to L.S, ❑Ezport tri US. rt of anlry�exil: <br /> Transporter signature(for exports only): eaving U.$,: +' <br /> 17:Transporter Acknowiadgmentof'Receipt of Maleda 2`. <br /> 12 I Transp PrihtedrTyped Name ISir Ntonth Day Year <br /> 0 014 <br /> ; Pilinted/tTid4ame <br /> Montt Day Yea <br /> 1- r <br /> 18.Discrepancy <br /> 18a Discrepancy lndiRalign Space El Quantit ❑T e ❑Padfaf Refection Elf <br /> ulrRejeciign <br /> p .r Type , ❑Residue <br /> Manifest Reference Number, <br /> 18b.Aitemate facility(or Generator) U.S.EPA 10 Number <br /> L<1 Facilily's Phone: <br /> 18c.Signature ofAifernate Facility(or Generator) v I Month Day Year <br /> d <br /> 2 <br /> N19,Hazardous Waste Report Mana oment Method Coi as(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2 3. <br /> / W 4. s4 5 <br /> f <br /> 20.Designated Facility Owner or Operator:Cenificatfon of ra eipt of hazordousmalerlalstoover d by themanifas f as noted to item, a <br /> Printelyped N ear <br /> EPA Form 8700.22(Rev,12-17) Previo s editions ar3 ob$olete. V FF EDFAi 1LITY T4 GIrNERATOR <br />