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<br /> Please print or type. A*1'. r Form Approved,OMB.No,2050.0039
<br /> UNIFOR�M HAZARDOUS 1 Gonerator 10,\um}r�F 2.'a; to F�]�{((�p7gcy?R;ttsf�ns fl�gnQJ� d.Manifest
<br /> Tracking
<br /> Number �(j{)(\1�16J-J 4VASTE MANIFEST j 1006'76`2312
<br /> 5.Gonerators Name and Mailing Address : " enaretor's Site Address(if different than mailing address)
<br /> Cisco lir Systewls In,�
<br /> 214 27th St
<br /> 8t1GRAM NTO CA 95816-3201
<br /> Generator's Phone: 31 L,"f}LI" -• "0r'
<br /> aY ihi''s T PaC U.S.EPA ID Number
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<br /> 7,Transporter 2 CoalName - U.S,EPA ID Number
<br /> CLEAN HAIN CtRS "t✓NVTI�M11 1tr1NTt=h1.. ,syc T�1Ca
<br /> 8.Designated Facility Name and SiteAddress CLEAN HARBORS SAN JOSE U,S,EPA to Number
<br /> � �1'1 BERR f Esau ROAD
<br /> Sf i4 JOSE � CA 95133.
<br /> 408-441-0962 CAL1059 43—i lD
<br /> Facility's Phone: t _
<br /> ga, 9b,U,S:DOT Description(including Prope Ship ing Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit 1�.Waste Codas,
<br /> NPA and Packing Group(f any)} No. Type Quantity WI,Nol.
<br /> t NON P,CRA H A J),US 'WAS].5 SO ck� �i5� � t7Di t' �?
<br /> o .i '� E��19,,. Pi TROL.I-Ah 4�YI)4tClCF�r�CARBONS 3) ell,
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<br /> 14.Special Handling Instrucliori ridAddifionai Information TSt3;S:l 7 9232 3 #l3 3793, CSE;,.,
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<br /> 24H Ei(CRSENCY4800 -468 17180—CH/SKI TF I--Co nt rasst Y- ---By 9.011P ��or cr�>' f r � .� ency Al.ti hlora t
<br /> on 'initial tram ort t10 add or sttbst tuts additiurl'3 "tr,ansDarter s on nen1�ra2ot0 s b�Il
<br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment arefuliyend accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked and labeledfplacarded,and are] ?II r spI',
<br /> n proper condition for transport according to applicable International and national governments]regulations,If export shipment and I am the Primary
<br /> Exporter,i certify tha the contents of fill rlons gnconform to the terms of the attachad`EPAAcknowledgment of Consent.
<br /> minlmizatlonslaa entde in 40 CFR 262.27(a)(if I.am a largo quaniilygeneratar)of(b)tiff am a small.qu n1(ty ger erator}is true:
<br /> era eiot�s Pri ped Name;, "5,goa a Month Day Ysar
<br /> 16.internalio Shipmer Is ff�-I�
<br /> f4G,
<br /> import to U.S, ❑Export from U.S. ortof antry/exit:
<br /> z Transporter signature(for expons.oniy): S.:
<br /> rx 17.TransporlerAeknowiedgmentofRecetptofMateriits
<br /> 12 Tninspqdg 1 PrinledfTypedName Signatd ,x Month Day Year
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<br /> Z Trans pr 2 Pr ed ypa Name Si ionl Day 'Year
<br /> 18,761scieparicy
<br /> ilea.Discrepancy Indication Space' r—� li "'
<br /> Quantlry' �• F1 Type Residue ❑PaHii;Rejaction El Full
<br /> IN
<br /> Manifest Re(erenceNumbar:
<br /> 18b.Alternate Facility(or Generator) U;S.EPA ID Numb,
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<br /> LL Facility's Phone:
<br /> r3 18c.Signature ofAlternate Facility(o-Generator) Month Day Year
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<br /> 19.Hazardous Waste Report Management f eihed(Bodes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> o t, /if ,2. 3. 4,
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<br /> 20.Designated Facility Owner or Operator:Cenifical'rrofjrere(pl ofit`a ardous materials covated by the manifosi except wUed inypem 1¢a
<br /> r 41Printed pod Nam (Y �' t Srgnalura �y7„— ,✓�� Mon h Day �r
<br /> �/( -:. l.f ���✓✓✓"'"` 11`J
<br /> EPA orrtl J 0;?2((Ret 12.1 PreviQuseditionsare bsole(e,.- —! �� ! r
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<br /> '743,525 �' r e �,;� SIGNATE FACILITY 0 GENERATOR
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