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t'"-76 <br /> 'yawn i r„.• � �,�y <br /> Please pnnt orlype. Form dosigned for use on elile(1 •pitch)typewriter;} � t r JAM Form Approved,OMB No.20,50.0039 <br /> `' 11.GanwalorlDNuftibet2.Pagel of 3.Emergency Respons Ph o 4.hlamfestTrackng NumberUNIFORMHAZARROU3 cr {WAS7E MANIF>5T . . ,. .t1r , `l_:zk1J �L7 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if dIfferent than mailing address) <br /> 214 27th St J <br /> Genetator's Phone: <br /> 6.Transportar.l Company Name U S.EPA Mumbor <br /> SAFETY--KL.'«EN SYSTEMS, lliqc <br /> T Transporter 2 Company Name. tAS.EPA ID Number <br /> t <br /> 8.Designated Facility Name and Site Address (USS ePXID Number. <br /> CLEAN 'HARBURIS-SAN ZISK, LU;102LUEOWSSA, ROOD <br /> 408-441-0962 <br /> . L.., / � .y r .{ � <br /> Facility's Phone: <br /> �08 4 t 1-0` 62 CA0' '59�19'.31 k� <br /> ga, 9b.US,DOT Description(including Proper$hipp ng Name;Hazard Class,ID Number, 10,Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if.any)) No; Typo Quantity Wt:Nol. <br /> X i NA1993r Ct7(YtMSTi KE -LIQUID 4 P:?:.8,y DIN 91 X14 <br /> IDEQA#lj�r KICYCL,OPEN-rsIL;clx6r~COMBUSTIBLE LIT])' P0.j III <br /> .Y <br /> 2. <br /> LU <br /> 3. <br /> d <br /> 14.Special Handling Instructions andAdditional Information ,,p S 9 t'7 r� 127202.72 <br /> }QL'a�.�sl �};rli��''t':1�3r t�6�i/:r.0Lt. <br /> 1iER13#128 <br /> 24 HR. NOGENCY. #I-MI-469-1760° (SK x1~'1) X 13/4,otl7�� <br /> i' Ci rt Ch1 - n ♦ ;r” .. z.�, h x+ a"t'S. Y <br /> 5 Ef2A OR'$/ . :S CER FICA I N; h re y ec are t a gte.co tents o i I cons nrnent are to lyan ki re a y escribdd abov %yl"proper'shipping name,an7 are dassified;packaged, <br /> marked and labaled/placarded,and are in ati:respect do proper condid ndor transport accordingto applicable:international and naffonaGgovemmentei regulagons.If export shipmenfand l am 1fiePdmary <br /> Exporter,i'cettity'that It a cgntenfeof tl s c,isfghme.t coof6rm to gie::terms of the aback6d EPAAcknowiedgmenf of Consent. <br /> I certifyfhat ibe waste miniinizati6n statement idpngf d in 40 CFR:262,27(o){if l am a large quantity.generalorpor(b):(If lam a small gganilty generator)is true: <br /> atol'S/o nPsipf ited/Type N .e Signature Month Day !Year <br /> ._r 16.In 9 Shipments t �+ _.. <br /> F ` r�. ❑Import to U;S. Export from U.5. Pod of entry/axil; <br /> Transporter signature(for exports on y): Date leaving U:S.; <br /> Lw 17,TransporterAcknoMedgmenkofReceiptdMatedale /�l <br /> i2 Tmnsp r 1 Pdnted/Typed Name Sig Month Day ;Year <br /> a y f <br /> Q7ranspo er 2' dote .yped Name Sign ure Monlfr: ay Year, <br /> 18.Discrepancy <br /> 18a.Discrepancy IndicationSpaco <br /> p y ❑quantity Type residue �•PsrUatRajechon FuII Rejection <br /> Manliest Reference Nrimber: <br /> 18b,Alternate Facility(or Generator) U,S EPA iD Number <br /> i� <br /> ti Facility's Phone; <br /> LU <br /> 1867 Signature of Allemato Faeriity(of.Generafor) Month Day, Yeah <br /> r <br /> 19.Hazardous Waste Report Management Method Cddes(he;;.cotss for hazardous waste,Uealment;disposal aptl`recydlrig sysCems} <br /> Uj <br /> 21. <br /> 20.Designated Facility Owner orgpsralor•.CeitiOpadop of r efpt:of hazardausmateda(;;covared bytha;manifestez tas nded.ln Ilam 18a r.�' <br /> PrintedtfYP. . ms' SignaLl 1:' <br /> ture Manu pay ea <br /> EPA Form 8700.22(Rev.3.05) Prevlous editions ere ob otele, DESIGNA( -t' CILiTYTO GENERATOR <br /> 1)7129864/40359361 <br /> ,r <br />