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IN n#fir .'SK SH 4) 2188':-a50w <br /> F case print or type.(Forts desfori9d for use on elite(12-pitch)typewriter.) ~' '7 Form Approved.OMB No,2050.0039 <br /> ji- 6N11FORM HAZARDOUS 1.Venerator ID Numb r 2,Page I of 3:Emargenoy Response Phono 4.MM�an�i"feystTraoking Numbor } <br /> MANIFEST L" ( 3utb�1''# t-4100-466-17 u'i} t 4. +1 315 8 eX� SKS <br /> oneraloes Name and Malang Address Geneators Site Address(if different thanmating address) <br /> i'ri't3, Air sy�iteus Ilii <br /> 14 c,ti, <br /> 8ACRPMENTO CA 95AI15-31101 COP <br /> Generators Phone: 916 -4.44 2 -S <br /> 6.Transporter 1 CQm an Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name �, , U.S,EPA ID Number <br /> B,Designated Facility Name and Silo AddressU,S.EPA ID Number <br /> C' 1 AN HARBORS SAN JOSE- LLC <br /> 1r 21 BERRrYESSA ROAD <br /> a IN JUS'E q CA 95A33 <br /> rr�ri�-•441-�Pd':6 5 fv�l��t �4��t s'1� <br /> FacilitysPhone: 4 <br /> ge, 9b,U.S.DOT Description(Including Proper,Ship Ing Name,Hazard Class,ID Number, 10.Contetne(a 11:Total 12.Unit 13.Waste,Codes' <br /> HM and Packing Group(If any)) No. Type Quantity Wt./Vol. <br /> Ina, t. �lj04 R�,RA �4rNA, DOUS WASTE. OL.1 :3 <br /> :D% DIN P 2 <br /> o (C%F.t.l�r :[, PETROLEUM tl4`I ,OCf)Rr O la) 3 441 <br /> 2. <br /> w j <br /> 3. <br /> it <br /> d. <br /> T4.Special Handling Instructions and Additional Informal on r , <br /> 24 HP EMCERGENC`( �1^r�k�171'-'��3�17cr±� {iK / TQ) <br /> !! rr. ., n .� rr v r r. izx t n —�T 1" �taA4�' I <br /> 16: G5NERATOR'SIOFPEROR`S CERTIFICATION:I ereby dedare lhakthe conlenis of lh s consignment aye to i�uralely described above:by the proper shipping name,and are classified,packaged, <br /> marked and labeled/piacarded,.and.bre in all$spa its in proper condition for transport according to applicable internationaland national governmental regulations.if export shipment and i am the Primary <br /> Exporter;I certilythattha content§:of this eons nm nt.:conform to the terms of the attached EPAAcknowledgment of Consent. t <br /> I certify that tho este,min)mizalion Iatement ldent!ad in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(if I.am.a smgl6gyantltygenerat r)Intrue, <br /> an gotsfOfferors rintetllT'ped�la e r 5lanature5lanatufs Month Day Year <br /> -1 16,inhimStional Shipments <br /> rDimport to U'S, El Export from U.S, .,./pod of 6111 lexiC <br /> Transporter signature(for exp l only): ,..pato leaving U.S:: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transp d91 Prinled[Typed Name Sig p3 ure ,r+ Month Day Year <br /> CL <br /> f i 77 )`✓t o/� <br /> Z <br /> Transpo er. do etltiyp d Name 5!gnalure month Day Year <br /> i -� <br /> 18.Discrepan'dj <br /> 18a,Discrepancy Indication Space Quanpry ❑Type ❑Residuerr 0Full Rejection <br /> I <br /> Manifest.,Reference Number: <br /> 18b.Alternate Facility(or Generator) t1:S..EPA1D Number <br /> a <br /> V , <br /> LL Facility's Phone: <br /> i8c.Signature ofAiternaleFacility(at Generator) Month Day Year <br /> Z <br /> 19 Hazardous Waste Report.ManagomordMethod Code (i.e.,codes for Hazardous wasla(reatmant,disposaf,and recycling systems) <br /> 20.Designated cility Owner or Operator:Cedircatlon a 1 receipt of hazardous materlals 5overridby the menlfast except as noted in item 18a <br /> tedlfypedjr`\Fame y' 8i nattrie"~4 Mapih Qa� Year <br /> EPA Forri 8700-22(Rev.3 06) revious ediilons are o,solete, l J ESIGNA CED FACILITY TO C, E AOR <br /> it7,1ii57;-;/7 3i'2 <br /> y <br /> E n. <br />