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d <br /> SSI_ SK SHIP* 28928460 <br /> Please Print or type. �f E� Forme proved,9M6 No.205{0-0039 <br /> WASTEMPJifFE37 s 1,CAmeraux <br /> CAP, Numbs, "I S I 2 PagstU 3;�. «�{p�@ X0071 8850 SKS ' <br /> 5.Geneeatm'a Name and WPM Address Generator's&WAddtese iff different than mastrg a kites) <br /> IVFI C 'rips 5hT <br /> CA %A.—cavo <br /> SYSTEMS INC U.s.EPAfDNumbar TXROWS1205 <br /> T Transporter 2 Company Name U.S.EPA ID Number ' <br /> CLEAN HARBORS ENV SVC INC. HAD039322?50 <br /> &Deslgruitod FacKy Name"'te Address CLEAN HARBORS SAN JOSE U$.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> 408-441-8962 SAN JOSE . CA 95133 CAM9494310 <br /> Fad' s Pt1me <br /> ga. f.US.DOTDmmpban(including Proper Stopping Name,Hazard Class,lD tea lIK 10.CdM ws; it.Tow 12.Und 13.Waste Codes <br /> HM andP P9G 4(ffany)) No. Type 0iard4y WtNti. <br /> a 1 N3N—RCRA"HAZAR1)OUS WASTE, SOLID DM P 223 <br /> o OJIL FILTERS) <br /> z 2. <br /> W <br /> C9 <br /> 3. <br /> ,f' r <br /> 4. _ <br /> i <br /> a <br /> 1,speow Handing Invinxilm and Adson TSD.SJ Af}ks 1prcir a CLQ t <br /> i <br /> 84H E'-4ERGENCYOB@0^468«1760--CHlSF(t'TFt-Cnntraet retairtes! by �.tner# a tt � tt#horsyGDAni or to add an substitute additional trA <br /> i <br /> 15. GEFIERATOR'SPCPFbER4R'S 4 RTIFlC 1ON:l Weby declare that the contonls of this caceignmetd aro tiny and accurately da cribed above by#*proper shpt nerne,Ware dasslW,Packaged.. <br /> marked ami fabde ft acerded,and are In all reel)"in proper c dfW for transport atx AN to app[lo"nlemaaareland na6mal g>wemrrcemal regulat one,"expert ehipment and I am the Primary <br /> E,W4(.i ost*that the odntams of Cos oanaigunantccnbrm to the temtsof the attached EPAAdurowledgmentof Consent. ' <br /> I certify that ate waste rNNTOet on statement identified in 40 CFR 26227(x)(I t an a large quantity generator)or(b)GPI am a small quarfO garmatdr)Is fors. <br /> GeneraWSIOP:ero?s PrktedRya d News Siralroe , : ear <br /> .: <br /> J 16.nlenmfimtai Sttpmerus �t <br /> p_ ❑Import b U.S. Lt Export 6om U.S. Part of eotrytexk,. ._ <br /> ? Transporter signature(for-p—only): Date!eavng U.S.: <br /> ixIT.Transports,Arluwy4edgrtere offWcWofMatedafs <br /> uj <br /> Tra r i N-nbr Typed Name Si3nahrre Month Day Vear '.. <br /> 0 13o j M <br /> z Transporter 2 Pri,*&Typeif Name hire Manch Day Year <br /> J. r <br /> 18.Dlsrrepumcy ' <br /> 18a.Discrepancy Indication Space ❑ ��----77 <br /> Quantity ❑rypo ❑Residue Imo:P Rejection Fu4 Rejection i <br /> Manifest Relarenx Numtrer: <br /> 16b,Alternate Fadty(or GetsYator) U.S.EPA iD Number <br /> J <br /> v <br /> ua Fadiy's FRwne: <br /> ft Signals of Atemde Favi ty(or Generator) Month Dar Year - <br /> 6 <br /> Z <br /> 14.Hazardov; Waste R Method Codas fire.,dudes for hazardous waste treatment,disposal,and recydtng systems) <br /> G 1 2. 3. 4. <br /> Z0 t'lesigrrato:i Fankty a Cer[T o1 rdpus tnatanats covered nY the menilaN exwpt as nod <br /> PrInWOypodName 1, <br /> EPA fonr8700.22(Ray.12.17) toused(tions a DESIGNATED kCfLlfYCOP •ti, <br /> 1)7044MAK VEVCHiSMANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e•MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDF <br />