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i <br /> SSI SK SHIP# P26%5537 = <br /> Please print OL19AW 4 Form Approved.OMB No.2050-0039 <br /> UNIFOR HAZARDOUS 1•Generator ID Number Elam 2.Page 1 of 3. me R e P 4.Manifest Trackin Number ��++v <br /> W E MANIFEST 5 "' f L ` 1 <br /> 5, enerator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> .� i A ( c 1 ( a' i € <br /> CA <br /> Generator's Phone: w' `+ <br /> 6:TrMO=1.PR SYSTEM INCU.S.EPA ID Number TX 8000081205 <br /> 7.Transporter 2 Compan Name U.S.EPA ID Number <br /> CLEAN HAI1 ORS ENVIRUNMIENTOL SVC INCA <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAID JOSE U.S.EPA ID Number <br /> 1021 BERRYESSIA ROAD <br /> SAN JOSE � CA 95133 <br /> 'f4M-441" 9i��Ai�. <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Wfiste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 1. RON-RCRA HAzAR ous WASTE, SOLID , DM. P nn <br /> o (CIL FIL1`ERM <br /> Z 2. <br /> w <br /> C7 � <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information TgtD t ,J 78205489 SP213 36 CS8,1 <br /> 4HM RCENCY##800-468-17 -pCN/SK/TFI° Contract retained by generator confers jency authar°i ,y <br /> on initial transPorter to add or substitute additional transuorters on erg w's behalf, <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described ave by the proper shipping name,and are classified,packagedr <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national ggyernmental 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 EPAAcknowledgment of Consent. � <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a sibaA'4ntity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name SignatureMonth Day Year. <br /> �5 <. <br /> ^A{9£-'Y J kir•` <br /> 16.International Shipments <br /> El <br /> Import to U.S. El Export from U.S. Port o,f entry/exit: <br /> z Transporter signature(for exports only): Date leavirjg U.S.: . <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedfryped Name } .A Signature Month Day Year <br /> CL <br /> t ' ! <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> aF <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityType❑ yp El Residue ❑Partici Rejection F-1 Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J ti c <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) _ Month Day Year <br /> Q <br /> Z <br /> us19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed(ryped Name Signature Month Day Year <br /> EPAc r.)11 0 2 R�v1 }21 )�p evious editions are obsolete. GENERATOR'S INITIAL COPY <br />