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Please print or type,(Forrin designed for use on Illo(tit-plich).typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Ganaraicitio umber 2.Pap 1 of �4 Eagqq��Refry PLI pq', 4.Manifest Tracking Number <br /> [I fl)L 0 Q1 V1 1:It 3 G 0 L J" a 10 <br /> • WASTE MANIFEST 1 IbO 0 vi <br /> 0_11 ,19-705 SKS <br /> 5.GeneratorsName and Malting Address Geinaraloes.Sile Address(if difFerentihan mailing address) <br /> .i <br /> iri'o� <br /> � 71,;h 9*t <br /> , ' <br /> Generators Phone =# <br /> Jal?y a <br /> U,S,EPA 10 Number <br /> XR 0 0 0 0 6 1 <br /> 7,Transporter 2 Company Name <br /> U,S.EPA ID Number <br /> 8.Designated Facility Name and Site Address I EME'AN HARBORS 18(na J118E.' U.&EPA ID Number <br /> 1 21 BERRYP".6i"70 R13AD <br /> 1�11 N JOSE' <br /> Facility's Phone: i <br /> ga. 9b.U.S,DOT Description(including.PtoperShl' ng Name,Hazard:Class,ID Number, <br /> 10,0onlainers It.Total u,Unit <br /> HM and Packing Group(ifany)) 13,Waste Codes <br /> No. Type Quantity W1.1vol, <br /> U"I'EN I)tif 1, �"A 1)f Ill.S W 111rTl {,,cit."(w;), <br /> Dirt }r 12 31 <br /> L <br /> Z 2. <br /> LLJ <br /> 0 <br /> 1USpadlal7findllng Ins(ructions andAdditionAl Infooatim <br /> TSD fly r,1..3 13")`9".3 C.'rG <br /> i?4 1­1R <br /> I'llit'L_It� <br /> ' '476w' 6T(71 <br /> 15. GENtRATORISIOPFERORIS CERTIFICATION:I I areby declare that the 00i'llOntself this consignment are fully andaccuratoly described rivabbo.by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,are mall re'spec:sin proper condition for transport according to applicable International and national governmeh bythe <br /> regulations,If export shipmerit and I am Ola primary <br /> Exporter,I cerfify that the contents of this:conslilmne nt conform to the terms of the attached EPAAcknowledgmont of Consent. <br /> I perlify that the waste minimization statement Omit ad in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true; <br /> 'Oenaratof's/Olfaroes PrinledfTyped Name Signature <br /> Month Day Year <br /> _J16.International Shipments <br /> FlImporl to 63. ❑Export from U,S. Port of entry/exit; <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w17.Transporter Acknowledgment of Receipt of Male rp"Is <br /> Transp fw'r I Printedirryped Name Sigraluile Month Day Year <br /> 0 <br /> a. <br /> , _7 "e-;1-/1" �*/'_"'Y <br /> Z Transporter 2 Printedirryped Name Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quan* ❑Type El Residue nparthl Rejection ❑Full Rejec116, <br /> I i I <br /> Manifest Reference Number: <br /> l8b,Alternate Facility(or Generator) j U's.EPA ID Number <br /> u.( Facility's Phone: <br /> Uj 18c.Signature of Ahernale Facility(or Generator) i Month Day Year <br /> L <br /> 19,Hazardous Waste Report Management Method Cpdes La.,codes for hazardous.wasto treatment,disposal,and recycling systems) <br /> 3. <br /> Li20.Designated Facility Owner or Operator:Cartification of i nelpt of hazardous.materials covered by[lie manifest except as noted in Item 18a <br /> Prinled/Typed Name Signature Month Day Year <br /> EPA�Fq�Vi_ . .2?,(Rqy. -0 <br /> 5) Prevlous editions are <br /> 73-, " " <br /> �� 1 - GENERATOR'S INITIAL COPY <br /> . <br />