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<br /> Pieade print or type.(Form designed for use on elite,(11 pitch)typewriler.), ' sA G � Forin Approved,OMB No,2050.0030
<br /> UNIFORM HAZARDOUS 1.Ganeta(or Ib Number �}�r,;3G,V1 2;Pago t of 31Enf�bl�y,'���se Phone: 4,Manifest Tracking ri�r ���
<br /> WASTE>MANIFEST U� 005,
<br /> {t'3} ✓y
<br /> 5.Generators Name and Mailing Address Generators Sllo Address(if different then mailing address)
<br /> 1:.1,20 toxr` K,3y'"ntomS Eric,
<br /> 214 2 r"'r h 1-1t,
<br /> SACRAMENTO
<br /> Generator's Phone: 916-4q42 'r15'
<br /> 8,Transporter 1 Company Name U.S,EPA ID Number
<br /> F'F&E—�,Y�,
<br /> SI{I EB14 3Yt31E''M8, t1: TX rr�i 31, p
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> CLEAN H;YRFJON3 ENW iIOUN1 S SCS INC
<br /> 8.Designated Facility Name and.61te AddressU.S.EPA ID Number
<br /> f
<br /> i i l3 N HARBORS. 5AN JOSE—-
<br /> -PRY ' `aft RW �1
<br /> l71r�f st.t�1 �R# Cir�1J1 fi 4� t t7 L f
<br /> Facility's Phone: ,r
<br /> go, 9b.U.S.OOT Description(inclu er"Il
<br /> g Name,Hazard Class,ID Number, 10,Containers ft Total 12,Unit
<br /> 13.Waste Codes
<br /> HM and Packing Group(if any))
<br /> j No. Type Quantity Wt./Vol.
<br /> o f[F OJJS WAS TE 301L IDS �a
<br /> t S`*.111 k 19, f��T ' .d:Sfri f•IYI71,C?i"AltBOHB)
<br /> ZLLJ
<br /> 2.
<br /> 3,
<br /> 4.
<br /> 14.Speelat Handling Instructions a d Additional Infor(ttada I C
<br /> HR -�DIIF
<br /> 't1 CF' r<h r� r!�. rt'[Sri _t
<br /> 15,'GENERATOR'S74F'pEkOR'SCERTIFICA ON: ih rebyde are ha^Iheco'neatsoflhrsconsTtj§EKare'uyan accuraeiydescrib9dad' `y epiopeisl pingname,andare classified,packaged,
<br /> marked and labeled/placarded,and are hall respac) In proper condition foriransport according to applicable international and national governmental regulations.If export shipment and l am the Primary
<br /> Exporter,I cedifythat the contents of this consItirmner I conform to the forms of the attached EPA Acknovdodgment:ofConseat.
<br /> ,f cantly that the waits min mizel(on slatornot l4n0i idin 40 CFR 282.27(a)(ifi am a farce quantity genOator).or(b)(if i am a small.quantity generator)is true.
<br /> ener�[qs/Offeror's iedffyped Name Signature ✓ _ Month D
<br /> ;{ ay Year
<br /> oA
<br /> .j 1P.International Shipments
<br /> F— ❑Import to U.S. ❑Export from U,S. Port of entry/exit: _
<br /> Transporter signature(for exports only): Date leaving U;S;,
<br /> L! 17.TransponerAcknowiedgment of Receiptof Materis`s
<br /> Transpo �Printedfryped Name SlgnIt f. �' Month Day Year
<br /> O {'/✓ y�
<br /> ;TrXanspqr2Pdnte yped a � " Signature � Month,,;•-bay Year
<br /> .4
<br /> 18. Iscrepancy '
<br /> 18a,Discrepancy lndicalion Space D Quantify• ❑Type
<br /> Residue ❑Partial Rejection ❑Full Rejection
<br /> _ Manifest Reference Number:
<br /> 19b.Alternate Faclllty(or Generator) U.S,EPA ID Number
<br /> 0
<br /> k- Facility's Phone: I
<br /> 18c.Signature of Alternate Facility or Generator) IfAonih Oay Yoar
<br /> Z
<br /> —may 19.Hazardous Waste Report Management Method Codes p,e.,codes for hazardous waste treatment,dispgsai,and recycling systems)
<br /> 1 i ' 3• a.
<br /> 20.Designated Facility Owner or Operator:Codification of eceiptofhazardousmaterialscoveredbythemonifost kxoplasnoted initem lBe
<br /> Prime pedgName Signal on D Ye r
<br /> 0 Q4, A 11
<br /> EPA Form 8700-22(Rev.3.05) Provious editions are'o11'solele. DESIGNATEO fAGICITY CO GENERATOR
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