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i' <br /> Please print%type (For(ii:designed'foruse on aliie�12-pifch)typekvriterl j .7 Form Approved.OMB No.2050-0039 <br /> UNIFORM`HAZAR, US' 1.Generator ID umbgr 2.Page 1 of 3.emergencyResponse Phone 1,4.Manifest Tracking Number <br /> [:j <br /> WASTE MANIF #'fIWIM# ,3C�0 S (3> iA.,,�tf� i•17f;Kfi C <br /> 5.Go11erator`sName-A MallingAddresS I Generator's SiteAddros§(it different than malting address) <br /> Cf sca Air sy,-+;0`ss 1.Ic <br /> r <br /> a 1 Vth R 0 <br /> S, :RAM-FNTC sJA '3 'f t�� 5c?0.1 <br /> PV <br /> Generators Phone <br /> 6.Transporter s Company.Name U,S.EPA ID Number <br /> 7.Transpbrier 2 CompaoyName U.S.EPA 10 Number <br /> G.L.I N .1JARAORS ENVIR. N 19VC8 Mr, <br /> 8,Oosignated FacllityName and Site Address ' U.S.EPAiD Numbor <br /> CLAM., HARBORS SAN JOSE <br /> 1,051 URRYESSA ROAD <br /> Facility's Phone: <br /> 408-441-096 + a N JOSS , CA '9 a1;n COD0594943 k O <br /> ga, 94:U.S.DOT Desedption(including Propai Ship ing Name,Hazard Class,ID Number, _10.Containers 11.Total 12,Unit 13,Waste Codes! <br /> HM and Packing Group.(if any)) ( No.� Type Quantity 44t Nol. <br /> } '1... ���{{��pp�� �7��++L�yyrr11 i� !y t� Ytt�,1 WA <br /> {�Y�t SOLIDS, <br /> r ti f� <br /> �. /fT NON iEGRA i;}t14rA )�i�]qL.�1{411r�i17��WtJ�`}1G7t�t�•y�'SOLI1,1�"i,.y Dx P <br /> U . t 7 DROCARBWt S):7 <br /> (i1 ' <br /> LU <br /> i9 <br /> 3. <br /> 4. <br /> i <br /> 14.SpecialHandling Instructions.end Additional info mall n <br /> T D SJ C 133,793 Cho, <br /> Cy OV-800"J68-1760 (SK TFI) ICA <br /> 2k'HN ENERGEN <br /> - iCAT_ ,i de a th' is ti i c'otls to antl W the A ov p ping Hama,arxiareclassified,packageiii <br /> marked and lsbaledlplacarded,and are f n ell re pec In proper condlllon for transport accordfng.to applicable internationatend national governmental regulations,if export shipment and l am the Primary <br /> Exportor,-i.cerdty that.tha contenlsrot this consi nme tOnform to the terms of the attached EPAAcknowiedgment of Consent. <br /> i certify,that the ttraste.minimlza,Oon statements entl din 40 CFR 262.27(a)(if l am a large quantity general r)oyjb((f)am a sm Ptd nilly generator)Is two, <br /> are sl OfferorsPngtedAypedNam �Signat Month Day Year <br /> -.r :16:Interhabonal Shipments . <br /> p= 'Import to I J.S. ❑Eicport:from U.5. Port of enby(ezil: <br /> Transporter signature(for.exports only):+ Date leaving VS.: } <br /> "17.TransporterAcknowiedgmenf of Race of Moterilis <br /> 12 TranspArK Pdntpdrryped Name 5lgnatt Month Day Year <br /> C> <br /> 1 <br /> 2- <br /> Tr-ansjrMfei2Printq y dName Signature �.« Month Day 'Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space puanii ❑Residue <br /> ❑Type ❑Parda[ReJection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> U <br /> ua. Facility's Phone: <br /> w 18c.Signalure ofAilernate Facility(or Generator) T Manch Day Year <br /> Z <br /> An19,Hazardous Waste Report Management Method C'des i.e.,codes.for treatment,disposal,and recycling systems) <br /> 3, 4. <br /> 20.Designated F c'ifity Owner or 0 erator.Corti of receipt of hazardous matadafs covered by the manirestexcept'�s naiad ins m t 8u <br /> PrintedrTy ed Name Slgnatuta ', ?Month Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editfe s ar off'olete, .' SIG ATED FAGiLITY'T p GENERATOR <br />