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�p 9 ( pd }typewrites 77 i602344362 SC PPW 7!20/2015 Form Approved.OMB No.2050-003'3 <br /> Please int or e, Form designed for use on elite 12- 'ch } pp <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A R O O O O s 9 6 S 6 te00a 4$3-3718 009877857 F LE <br /> 111 5.G�tU� sN�r leU nd M�ing.iddress Generator's Site Address(i different than mailing address) <br /> 4215i816oaeing Wal► SAME <br /> Stoddon.CA 95246 <br /> Generators Phone: 12081234-0202 <br /> Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Service.Itr; M A D 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors San lase LLC CAD 0 5 9 4 9 4 310 <br /> 1921 Berryessa Road <br /> San lose.CA 65133 <br /> Facilit es Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nei. <br /> ce 1' NON-RCRA HAZARDOUS WASTE.SWDS,(50R0.SILICATE t, <br /> j Fl�tT,ZiN1COXIDE3 Q(p `t�.Za —.... ... ..:.__..�.. _..,.. <br /> `E 2 <br /> l . <br /> i � w._. __... <br /> i <br /> 4. <br /> 14,Special Handling Instructions and Additional Information t <br /> 1 XH148295 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deciare:lhat the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to(he terms of the attached EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(If!.am a small quantily generator)is true. <br /> i Generator` Offerors P nntte►dflype Name igna n is may ear <br /> _ <br /> 30( C\— ti Cta19 a VC t;r It <br /> -r 16.international Shipments <br /> Fh ❑import to U.S. i ❑Export from U.S. Pod of entrylexit: <br /> — Trans er signature forexports on : Date leavi U.S.: <br /> c2 17.Transporter Acknowledgment of Receipt of Materials <br /> C <br /> Transporter 1 Pdnted/Ty3de Signalu ont ay ear <br /> Transporter 2 Printed/Typed Name Signature nt ay ear <br /> ce I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space quantity Type ❑Residue ❑Partial Rejection ❑Full Rejectlon <br /> Manifest Reference Number. <br /> E- 18b.Nternate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> Facii 's Phone; <br /> �� 18c.SignaWre of Alternate Facility(or Generator) Month Day Year <br /> ,r <br /> S2 19.Hazardous'Nast Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> c� 1' Hi4i 2' T <br /> 4. <br /> Ij 1 <br /> ` 20.0 ' ated Facility Owner or Operator.Certification of recelpt of hazbrdeus materials covered by the manifest exat as noted in Item 18a <br /> PrinIe5QPd Name I gnato Month Da Y <br /> 0 � <br /> ESE,Form 00-22(R v.3-0 Pre tons editions are obsolete., I ED E tLITY T NATION STATE{IF REQUIREE�) <br /> i Clean Harbors as t 0 app""ate permits for and ale coapt the waste the gene r rpj <br /> i <br />