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raa''L, SX SHIP# 2301967a6 <br /> Pease print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number OlIgL00 X361071 =1,,eJE�metg.5,e�sppll-se Pto%� 4.Manifest Tracking Number <br /> WASTE MANIFEST e110 r3E3 3 007276741 <br /> j 0 7 2 7 7/„I 1 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different then mailing address) r= <br /> Moe Auto Repair <br /> Z-1P55 S Airport tray At>tnd IYtoe <br /> STOCKTON _ CA 95206--3338 <br /> Generator's Phone: � � �� — �k <br /> B.Trd�R-p��i j„ompaPy q�q SYSTEMS INC u.S.EPA IDNumber TX8000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Ct_EAN HARBORS ENV SVC INC. NlgdD039322R50 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SPN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE CA 95133CA'00594943 <br /> 408-441-0962 t0 <br /> Facility's 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)} <br /> No. Type Quantify WINaI, <br /> a n 1 NA3077 HF17ARl OUS {•,ERSTE SOLID,r W.0.S. to DZI@E D006 D007 <br /> o , (LEAS, CHROMIUM), 9, 66 TIT <br /> WOE 181 <br /> z 2. IVflII--i2C R ) #rtf��#��t81 lra -tdsS'T F;-mit,I13 . - - -- I)k�i _--- p---,- �- <br /> (BFB:--FTLTEP6S .----' <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD.,SJ 81879011 M030843 CBS; <br /> 24H EMER09NCYOBOO--468-7.760-CH/SK/TFI--Contract retained by generator confers a envy authority <br /> ort initial. transporter to add or substitute additional t;r^ansoorters an nenera .er' s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the oentenis of INs 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 international and national governmental regulations.If export shipment and f am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> cartify That the waste minimization statement identifed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if 1 am a small quantity generator)is M. <br /> GeneratorsfOfferors Prfntedrryped Name Signature Month Day Year <br /> a 16.Intematfonal Shipments <br /> ❑Impart to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(far exports only): Dale leaving U.S.: <br /> LU 17.TransporterAcknowledgment of Receipt of Materiats <br /> �2 Transporter 1 PrintedlTyped Name Signature r Month Day Year <br /> Transporter 2 PriAtedlTyped Name Signature ! Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type ❑Residue L1 Partial Rejection L1 F.11 Refection <br /> Manifest Reference Number. <br /> 16b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> FaciliVs Phone: <br /> rOL— 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 2• 3. 4. <br /> 20.Designated Fadlily Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Be <br /> PrintedlTyped Name Signature Month Day Year <br /> EPJ la l 9 3f�'1�- �!]lP ious l 7 e1 t�ll'i' GENERATOR'S INITIAL COPY <br />