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M <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) C11352738 APP:aidce 1.07DT19.2 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST C a 1 0 0 0 2 3 2 1 8 1 i (800)4833718 0 0 0 3 7 9 6 4 FLE- <br /> T-Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 4707 Pale T-0313 <br /> Ve 13 <br /> SLcddDn,CA 95207 <br /> Generators Phone: 209 476.8081 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Env SerAm Inc M A D 0 3 93 2 2 2 50 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.O Q'ned Faa"VWn ite Addr�sg C U.S.EPA ID Number <br /> 1021Borysm <br /> eRoad LL C A D 0 6 9 4 9 4 3 1 0 <br /> San Jane,CA 95133 <br /> Facility'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 13.Waste Codes <br /> HM and Patting Group(if any)) No. Type Quantity WI.Nol. <br /> 1 WASTE AEROSIX8.2.1,1UNIMAON€ 343 D001 <br /> X 001 DF 0000 S P <br /> w 2. WASTE OXIDQING LIQUID,CORROSIVE,N.O.S.,(OXYCLEAN, 343 D001 D002 <br /> X BLEACH),51,UN3098,PG 11 0 0 1 D F 0 0 0 1 1 P <br /> 3. NON RCRA HAZARDOUS WASTE LIQUIDS.(LAUNDRY 343 <br /> DETERGENT,SOAP)M&NONE,NONE 0 0 1 DM 00 18 3 P <br /> 4. <br /> 14.$pect(5 Instructions andAdditionlg)oWn <br /> 3. LOCi7N LP 1 x55DM <br /> 2. LCCRO LP 1x5DP <br /> S0901352736 FLEETt#442108 LPB TARGET-021 <br /> 15. GENERATOR'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 govemmental 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 /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ii I am a small quantity generator)is We. <br /> eri tor's/ erors Pnntedfryped Name Signature j Month <br /> 1 09107 <br /> Pi <br /> 16.IiYematibnal ShipmInts <br /> F— ❑Import to U.S. ❑Export from U.S. Port 44/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Transporter 1 Printedff d Name ignatur on ay ear <br /> a MARC SANMGO III Q 01 09 07 <br /> zQ Transporter 2 Printedffyped Name Signature Month ay ear <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J " <br /> U <br /> Q <br /> LL <br /> Facilitys Phone: <br /> LU 180.Signature of Alternate Facility(or Generator) Month Day Year <br /> H <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> o ,. 7. <br /> *11It1 2. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manife ,cept as noted in Item 18a <br /> Pad N me Signa Month 0 Year <br /> [�4 s��f11 / 1 6 14 a7 <br /> Clean ttaaroorsPtias meP� � �and� �ft��tM qgn@CILITY T E N STATE(IF REQS <br /> 10076.0823 - " ' <br />