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I., , i C. GO 1 - <br /> Please print fX type.(Form designed for use on elite(12-pitch)typewnter.) '--J?525;.: AQP:L'I'E:C3'..0?�'.T`,�:c Forth Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 0.Manifest Tracking Number <br /> WASTE MANIFEST c a i 0 J e 2 3 2 1 8 1 t ;�_��453-3718 0 01089944 FLE <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than marling address) <br /> a,r.1et Stora T 0313 <br /> 473 r Pac;-c Ave <br /> �tocktor,,C-A 95207 <br /> Generators Phone:209 476-8089 AT-NK Reverse Logistics Fracess <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Env Services Inc M A D 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name ��e U.S.EPA ID Number <br /> 8t�s�naM� 0�5SdI1nJ052di±s4 U.S.EPA ID Number <br /> 1021 9erryessa Road L A U U 5 9 4 9 4 3 1 U <br /> San Jose,CA 95933 <br /> Facili 's Phone: (408) 441-0962 <br /> ga 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt./Vol. <br /> 1WASTEAEROSOLS,2.1,UN1950,NONE UMITEDQUA.NTITY 343 001 <br /> o }� 001 DF 001 0 P <br /> UJ 2NASTE FLAMMABLE LIQUIDS;N.O.S-RETROLci.M 343 D001 <br /> c� v DISTLL•,ICJf,3,L'�J1�93,FGll 0 0 1 D F T 0 0 1 0 P <br /> 3NON RCRA HAZARDOUS WASTE 343 <br /> UQUIDS,(OIL),N/A,NONE,NONE 0 0 1 O F 0 0 1 5 P <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1. LCCRQ LP 1x5013 3. LCCRN ix50P <br /> 2. LCCRO 1x5OP <br /> WO#CJ 1629334 FLEET#5234 LPO TARGET 0-21 <br /> 15 GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that 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 international and national governmental 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen r( T I am a small quantity generator)is true. <br /> enerato s10 eror nt ype Name gni ure Monthay Year <br /> Q.Y►h N rA-[JXI10 0 2 7 <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export from Port of ent <br /> Trans iter signature for exports only): Date leav <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LI <br /> � <br /> Transporter 1 Printed/Typed Name Signature <br /> on ay Year <br /> o Sean Spier 10 102 Ip 7 <br /> Z Transporter 2 Printed/Typed Name SignatureMonth Uay Year <br /> Q <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 17- l8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> Q <br /> LL <br /> Facilitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 5, <br /> H 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 12.1 2. (j r Lo 3. H 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted em 18a <br /> Pdnt yped Name S naN Mpnth Day Year <br /> �Ptr4�4a 8°7s � � �iC.� r�'t°,���nd will accept trse waste the generator is 4�F I � NATIQN STATE(IF REQUIREFT� <br /> 10197.0068 <br />