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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) CJ1445636 APP:Cholce 1.07DT19.2 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C a 1 0 0 0 2 3 2 1 8 1 1 (800)483-3718 000570029 F L E 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Target Store T-0313 4707 Pacific Ave Stockton,CA 95207 Generators Phone ATTN:Reverse LO Ishcs Process 6. ransporter 1 Ccmpany Name U.S.EPA ID Number Clean Harbors Env Services Inc M A D 0 3 9 3 2 2 2 5 0 7.Transporter 2 Company Name U-S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors San Jose LLC C 1021 9errye»a Road AD 0 5 9 4 9 4 3 1 0 San Jose,CA 95133 Facility's Phone: (408) 441-0962 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total Q.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes Ir 'WASTE AEROSOLS,2.1,UN1950,NONE,UMITED QUAN17Y 331 D001 X 0 0 1 D F 0 0 0 8 P W Z 2WASTE BATTERIES,WET,FILLED WITH ACID,ELECTRIC 792 D002 D008 X STORAGE,8,UN2794,PG fit 0 0 2 D F r C C B 4 P 3WASTE CORROSIVE LIQUID.BASIC,INORGANIC, 141 D002 X N.O.S.,(POTASSIUM HYDROXIDE,AMMONIUM 0 0 1 D F 1 0 0 9 5 P 4NON RCRA HAZARDOUS WASTE UQUIDS,(BROKEN 331 SURFACTANTS),NIA,NONE,NONE 0 0 1 D F 0 0 0 3 9 P 14.Special Handling Instrudons and Additional Information 1. LCCRO LP 1x5 3. LCCRB 1X55 2. LBLA2 2x5 BROKEN IAE 4. LCCRN 1X15 TRUCK#35307 LAB PACK.PROFILE#fD21 15. GENERATOR'S/OFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable inlemallonal and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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 small quantity generator)is true. Generators/Offerors Printed yped Name gna a on ay ear CINDY TORRES LQ 4 130 P 7 -j 1 16.International Shipments l= ❑Import to U.S. Export from U.S. P entry/exit: Transporter signature for exports only): to leaving U.S.: � 17.Transporter Acknowledgment of Receipt of Materials w Transporter 1 Printed/Typed Name SigratureZff rZ K Monthay ear a ANTHONY BUSTAMANTE0 4 130 07 ZZ Transporter 2 Printed/Typed Name Signature Month Uay Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U S.EPA ID Number :3 U Q LL Facility's Phone: In -W 18c.Signature of Alternate Facility(or Generator) Monti Day Year Q Z H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyclirg systems) LU c 1 8 1'-' 1 2. I J_I L 3. 'l j•l 4. H � 20 Designated Facility Owneror Operator:Certification of receipt of hazardous materials covered by the manifest a cept as noted in Item 1 Ba �7 Pr me Na a �"O) Sgnatu Month Day Year Pit� a , . I v "i&S 6 * 17 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESO ATED FACILITY tADE£! EIG REfl111EiED) Clean Harbors;:has the appropriate permits for and will z----#6- the generator is shipping. 10122.1320