Laserfiche WebLink
SK 11-*'HT1,'P# <br /> pig.. §0 Print or type. RECEIVED NOV 6 201a Form Approved.OMB No.,2050-0039 <br /> LGenarat TD—Mmbor 2-Amp I of 3�.Emergency Response Phone <br /> UNIFORM HAZARDOUS WOW Tracidng.Numbor <br /> CAL .4,5 716f- --46,--1760 <br /> WASTE MANIFEST 01 11 3 q <br /> 1' 012887508 FLE <br /> 6,Gonerator's Name and Melling Address <br /> Generator's Silo Address(![different than malling address) <br /> Q f) -A I '13v F,t"'A 1:,T1 2 <br /> d'14 LR7tt-i St' ;;10 <br /> M,'RAMENTO CA <br /> Generator's Phone: 9 rt --ef 4 4—2 3 P.S <br /> 6.Transporter I Company Name <br /> U'.S,EPA 10 Number <br /> SAFETY—KLIZEN OYST-EPK3 lNG <br /> 7,Transporter 2 Company Rome U.S.EPA ID Number <br /> CLEAN HARBORS ENV I FJOI U112P-ITAL SVC; INC, <br /> 8.Designated Facility and Silo Addiessi— U.S.EPA ID Number <br /> M4'EAN I-IMMORS SAN JOSE <br /> 1021 BERRYESSA POAD <br /> Facility'$Phone: SAN JOSE CA 95133 <br /> 9a. 9b.U,&DOT Description(including,Proper 3hipping Name,Hazard Class,ID Nomber, W,Conlaloars 11,Val 12,Unit Waste Codes <br /> HM and Packing Group(if any)) No. TY'H Qunntlly I w(Bol. <br /> 1, <br /> Ce I)HIIH-- NON KRA HIPIZAROOLIS WASI-E 90-LIDS, P 3 <br /> 0 <br /> WEAXS, PETROLEUM HYDROCARBON'M, <br /> 2. <br /> w <br /> 4. <br /> 14.Special Handling Instructions andAddillonal lnlorrisfio� <br /> retainA.*d by gv�eratwr COTIfer-tt aq�iicy amthority <br /> 6G <br /> �'decrare that <br /> AFrH I hinaby" <br /> G A NATO ft811 R;R ffCAM—C'A-�l ' ` '; <br /> marked and fabeledtplacarded,and are In all rest acts In proper condition for trans 9 according to applImble International and national governmental regulations,If exp ad shipment and I am the Primary <br /> po <br /> Exporter,I certify that the contents of thIs consign nent!"conform to the terms of the attached EPAAckmeviledomont of Con <br /> that the waste minimization statement1do ilifieo to 40 CFR 262.27(a)(if I am a large quantity gone aikmalfquantl�,generator)is true. <br /> 6ertdrsl0lferor`sPrintedlT odN 8 <br /> yp a Signatu Month Day Year <br /> 16.International Shipments <br /> r— Expert U.S. ntrylaxit: <br /> ImportloU.S. s <br /> Z Transporter signature(for exports only): pdvlhg U'S': <br /> W 11.ffanspoqTA0XnoWedgmenl ofRocelpt ofMatedals <br /> 'Ile <br /> ign <br /> Trans -1 Pfiried/Typod Name S y 8 1 h Day Year <br /> VI/ <br /> 5!E Transporter 2 Pd6todTryftd�dflffi Signature "71)Z <br /> 57 <br /> 18.Discrepancy <br /> 189.Discrepancy Indication Space F1 Q.�nuty FITYP, El Residue Partial Rejection Dull Rejellic, <br /> Manifest Reference Number: <br /> I Ob,Alternate Facility(or Generator) <br /> U.S.EPAID Number <br /> Faclity's Phone: <br /> 18c,Signature ofAlternate Fadlity(orGenerator) th Day Year <br /> ig.Hatordous�Vaqe�eportMonagpmen(N.ethodCbdo (I-e;"codes for haardous:wasto treatment,disposal,and recycling systems) <br /> 2. <br /> �]3. . T. <br /> 20,Designated racillOwn or aralor:Certifica n c joc:09pfiazardous materials covered by the manifest except as not jqjIoR_jj1a <br /> Pdntedrryped NamF) Signature <br /> V-11 <br /> )rlv��A <br /> EPA Form8700-22(Rev.1.2-ITPtev-lous v DESIGNATED FACILI R)GENERATOR <br />