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Stah-aLCWifornio—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of a <br />Blease print or type. Form designed for use on elite (12 -pitch) typewriter. , "g 6. Department of Toxic Substances Control <br />Sacramento, California <br />UNIFORM HAZARDOUS 1 <br />1. Generator's US EPA ID No. Manifest Document No. 2. page 1 ation in the shad areas <br />WASTE MANIFEST%" r4� i j'+? Lr 4 y is n r fired by Feder <br />+.• t :.'+ of <br />3. Generator's Name and Mailing Address f *':� s A. State Manifest Document Number <br />286 868 <br />A. Generator's Phone f". 4 ] } .. ,- ;i • t f `. !:']`-� # f �{ �+ 1 <br />B. State Generator's ID <br />CV 5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID Reserved.] <br />t <br />Transporter's Phone <br />F�•'..:..' is i-; :.t S'S. <br />7. Transporter 2 Company Name S. US EPA ID Number E. State Transporter's ID [Reserved.] <br />J po [ ^red.] <br />J <br />Q F. Transporter's Phone <br />V 9. Designated Facility Name and Site Address <br />10. US EPA ID Number G. State FA. <br />Q CSU 14 4 r.!r, (95,; 4 9 4 3 j+_l <br />Z :LEAN HARBORS MAN JOSE. €.L <br />oc 1021 rel c��;�E :�tiA FiL1 r,gr,�s ; t <br />�,s .t C, C, F• L � 1 f 1. H. Facility's Phone <br />800', 54 - 3358 <br />V11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) 12. Containers 13. Total 14. Unit <br />No. Type Quantity Wt/Vol I. Waste Number <br />EE N4)14 -R(. RP, flAZArti:►twUS L I If State <br />3 G OIL, WATE:F1, SLL3DGF,1, Noll Crc € t ►.% i r.. 222 <br />E ` 1 1 j ' ri '• EPA/Other <br />N 1 <br />N b. <br />00 E State <br />A EPA/Other <br />C. <br />0 O State <br />R ti EPA/Other <br />ce <br />LU d. <br />C ^ ��- State <br />U <br />LU EPA/Other <br />rn J. Additional Descriptions for Materials Listed ve <br />Z K. Handling Codes for Wastes Listed Above <br />a. 1 b <br />Uj <br />Q c. d. <br />Z 15. Special Handling Instructions and'Additional Information <br />M ST R�r,1),) dl— J�:1li It t <br />Q EMERGENCY RESPF�s7C) 9h�Ei--1'7aS(1{ )4 HEI) . IF UNI)E;L3 il-ERABL4: RFTill,N TO GENERATOR, <br />ZS ?' <br />CORP AUT°tl.1PTUN.i m(-.) PiTAIN LICENSED `MO-E'QrTENT Cr"'kR1IERS NEC E 01 SAR V. <br />L <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />J marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />J <br />If I am a large quantity generator, I certify that I have a progrom in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economical)y <br />Z <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and Future threat to human health <br />Y and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Typed NomaSignature nth i Day Y <br />u T <br />i <br />R 17. Transporter 1 Acknowled emenf of Receipt of Materials <br />A Printed/Typed Name - <br />R ) {,•> . r� Signature Month Day,-, X t� <br />Li S <br />0 18. Transporter 2 Acknowled emenf of Receipt of Materials <br />TPrinted/Typed Nome ome Signature Month Day Year <br />L <br />R <br />J 19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />120 Fo ility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T Printed/Typed Name Signature <br />YMonth Day Year <br />DO NOT WRITE BELOW THIS LINE. <br />)TSC 8022A (1/99) <br />fA 8700-22 :., NFRATOR RETAINS <br />