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JJ 1702178570 SC PPW <br /> Please print or type,(Form designed for use on elite(V-pitch)typewritei, 1/4/ 017 Form Approved.OMB No.2050-0039 <br /> UNIFORMHA7ARDOUS I"enerator ID Number Z Page I of 3.Emergency Response Phone 14,Manifest Tracking Number <br /> WASTE MANIFEST JCAR 000099656, (1309)4133-3719 1 010886957 FLE_ <br /> 7 Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Quest Industries Lle <br /> 2519 Boeing Way SAME <br /> —StocktorvCA95-206;-- ...................... <br /> Generator's Phone:(209123"202 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Service,Inc. MAD 039 :322250 <br /> 7,Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors San Jose LLC CAD O-59494310 <br /> 1021 Berrvessa Road <br /> 4�33 <br /> San Jose.CA 9513 <br /> Facility's Phone: <br /> 98. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, Ia.Containers 11,Total IZ Unit <br /> HM and Packing Group(if any)) No. Type Quantity WjVol. 13,Waste Codes <br /> Cr NON-RCRA HAZARDOUS WASTE.SOLIDS.(BOROSI LICATE 191 <br /> 0 <br /> FRIT,ZINC OXIDE] <br /> 9 <br /> Z 2. <br /> LLj <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> 1.Clil 4 82 9 5 (0 n <br /> 165. GENERATOWSIOFFEROR'SCERnFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeleplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quant y generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offerors PrintedlTyped NameMonth 05—Y <br /> IZ4L 105M 1ear <br /> /? <br /> :_j 16.international Shipments <br /> El Import to U.S. ❑Export from U.S. Fort of entrylexit <br /> Transporter signature for exports only): Date leaving U.S.: <br /> LWU 17,TransporterAcknowledgment of Recdpt of Materials <br /> i Signature Month Day Year <br /> Transporter 1 Printed/Typed Name <br /> CL <br /> Transporter 2 PrintertlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue EIPartial Reject. ElFull Rejection <br /> Manifest Reference Number <br /> 18b.Aftemate Facility,(or Generator) U.S.EPA ID Number <br /> :3 <br /> CJ <br /> Ll F <br /> Ck — =-,.' <br /> Uj 18c. f Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 3. 4, <br /> Hi4i 2.I <br /> 20.Desi ed Facia Owner qrOperator ertifi receipt of h materials covered by the manifest excepLatAo4d In Item 18a <br /> Printe Sign Ma Y <br /> EPA Form 7 8700-22(R �r� Previous ed ions are obsolete. DJSIGNAIED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Harbors <br /> 11 <br /> Cleat H as the appropriate permits for and will attept the wat"Wienera or is 5 Ipplat <br />