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SAE SK C11-11I 0' ' ` Form Approved.OMB No.2050.0039 <br /> 1 t ewdteG) :� r.EmergOCYes dose Phone 4,Manffest Tracking NumberQease print or type,(Form designed.for usa on ell( (�2 p 4h).yR 2 pago K P ! t7:i,Generator 16Num.er y+ 'q'"1760 <br /> UNIFORM HAZARDOUS CALfttZt}yt3 � <br /> WASTE MANIFEST Generators Site Address(it different than mailing address) <br /> 5.Gen aloes Nama and MailingAddross <br /> Cisco Cir Systems Inc <br /> a14 27th st C{1 �t5 ; w t I <br /> 9)AC R{�Ma1TCl U.S.EPA'iD Number <br /> Ganerator's Phone: 116-444P-52 -------- ' <br /> 0,Transporter 1 Company Name <br /> j 1"ETY—KLEEN SYSTEMS, U:S:EPA IDNbumber y <br /> 7.Transporter 2 Company Name <br /> '1 U:S.EPAIDNumber <br /> 8,Designate Facility Name and Stie Address CLE€1M HARBORS SM J.0 5F <br /> i BERRYIESSA ROAD al 4!5133 CAD0594943i0 <br /> t,poi <br /> JOSE <br /> 408 41-0968 <br /> Facility's Phone: 18,waste codes i <br /> Name,Hazard Class;ID Number. 10.containers 4 it Total 12.Unit <br /> 93. 9b.U.S.DOT Description P Pro orShippi g No Type Ouantily Wt:Arol, <br /> HM and Packing Group(if any)) DM P Z <br /> RCRA HAZARDOUS WASTE 430L,,U a9 <br /> o ( t iia", , PE 1"�tC LIUMii HD DRQCARPONM i - -LA <br /> 2, <br /> w <br /> tD <br /> 3. <br /> 4. <br /> ( { <br /> i <br /> C13�/93 CSQI <br /> 14.Special Handling InstfuctoRs`and' dfidonalintorma lor4 TSD 3 JS\+y <br /> t o <br /> 24 HR Eft RGENCY #1-800- 56M 1760 (81{ TU ` <br /> Inproperare th condition for t tent ootaccoroNg to applicable mlernallonal and nations{govemmenfat regularlwns.if export shipment and i am the Primary <br /> 15, GENERATOR'SIOFFEROft'5 CERTIFICATIbN hereby declare thetihe coolants of Ihrs consignment are fu11y and aceuratYty.described above by ineproper ahippingname, are dassifietl,package, <br /> marked and labelediplacarded;and are in 811 s1l. e s I <br /> Exporter,i certify that the contents of Itus consign enccantorm to the terms(i the attachedrge quantity <br /> gene, <br /> ,to or( COMM, Month Day Year <br /> dify that the waste minimizotlon statement Iden lified in 40 CFR 26.2:27(x)(if,am a larga'quamity sig iatuor ar( (If 1 am a all qua ' enerator)is bua. <br /> soar orslONarars Pr(nteq.tTyped Name, 110 <br /> t rr--IIPortoteabylexit: <br /> 16.totem wnai Sli pments import Ito U, , t�I Export ham Us. -plo jeaving U.&; <br /> h— <br /> z Transporter signature(for exports only); Jr Year <br /> Month Day',. <br /> f7.TransporterAcknowledgmentofRecelptclMa�erial Signeto <br /> Transp i P etliTypedName <br /> 00 . Month Dayl Year <br /> a Signature <br /> Tr 2 Pdn ad m <br /> 18:Discrepancy Q parts{Rejection t_!Full Rection <br /> 1Be,Discrepancy Indic alion Space a `usnily <br /> ❑Type �Rest us <br /> i <br /> i Manifest Reterence.Numbar. <br /> U,S,EPA ID Number <br /> 18b.Alternate facility(of Generale[) <br /> C� <br /> Morilh Ray Year <br /> u`'-- Facility's Phone: <br /> U0 18a Signalure ofAiternate facility(or0eneralir) <br /> Z <br /> �............ <br /> hod ilea p.e..,cedes fochazardous waste realment;disposal,and recycling systoms <br /> 19,Hazordous Waste Re o snag ma tMel <br /> 2. <br /> 001 <br /> �� Yea <br /> Month Day <br /> 20.Designated Faci tty Owner or Operator Cyrtill Ilon uPcei <br /> rept of hazardous matadais coveted by lha mSigtnatura�Pt as ndad is i(em 18a. L^c✓Y <br /> PdntgdfTyped ame 7 <br /> x c v2 ( `l DES 1 ED FAC(L IT TO GE CRATO <br /> tom'' f <br /> A . ,a70n.o9 IRay.3.051 Previous editions are obsolete, <br />