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7J 1901719427 SC PPW 0/0/20i7 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Fuge 1 of 3.Emergency Response Phone b.Manifest Tracking Number WASTE MANIFEST G A 11000009656 :L ($00)48"718 011791290 F L E Generators Site Address.(if tlifferenl than ma+ling address) 2519 Boeing Way SAME Stockton.CA 95206 Generators Phone:tZ091234-0202 6.Transporter i CompanyName — US.EPA ID Number Clean Harbors Environmental Services,Inc. IMI A D 0 S 9 3 2 2 2 5 0 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors San lose LLC ^ , „ ,„ „ „ 021 Berryessa Road L.A D v U a 4 a$4 3 .i.v Ban Jose.CA 95133 Facility's Phone: — 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit t3.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtNol, 1•NOR-RCRA HAZARDOUS WASTE.SOLIDS.(BOROSILI�I�t M 7 i>31 FRIT,zinc OXIDE) Z 2. — W 3. — 4. 14,S I Handiin 1nsWctions and Additional information 1.t 398Zg95 "7*)( r"'&`V� 15. GENERATOR'SIUFFEROR'S CERTIFICATWN. I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,Padc*, marked and labeiedlpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.0 export shipment and t am the Primary Exporter,i certify,that the contents of this consignment conform to the terms of W.altached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if l am a large quantity generator)or(b)(if tam a small quantity generator)is true. Geneiatoes/Off es dnf ame •— Signature _ aye Year i6.Inte ation ipments rr----�� — r✓ ' _� i— LJ import to U.S, ❑Export from U.S. Port of entrylexit - _ Transporter signature for ex its only): _ Date leaving U.S.: w 17.TransporterAduwwfedgment of Receipt of Materials — Transporter i PrintedRyped NZa Signature With Dayle 00 2 Transporter 2 Printedrryped Name Month Year b- 18.Discrepancy — 18a.Discrepancy indication Space El Quantity ❑Type rM ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) — U.S.EPA ID Number J LL Facilit's Phone: LU 18c.Signature of AAemate Facility(or Generator) — Month Day Year Z _ rrnn 19.Hazardous Waste Report Management Method Codes(W,,codes for hazardous waste trealmont,disposal,and recycling systems) LU 1. 2. — 3. 4. H14i 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest excqpt as noted in Item 18a PrintedlTyped ame — Signa Month. Da r EPA Fomi 8700.22(R v.3-05 Pre tous editions ore obsolete.. — � jWjW1LITY TO DESTINATION STATE(IF REQUIRED) Clean tfamors l as t ie"pronate pemms for allow willattepti the Waste'Ifie,itene _