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t}I�17 A 1 Ji 1 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) a't 77� APP:Ch 3!ce 1.070119.2 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 f 0 0 0 2 3 2 1 8 1 2 (87L)483-3718 001087836 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Ta rgat St07e X313 471.7 Pa%'*':C Ave 5tzi6iton,CA 95207 Generator's Phone: 209- 476-SOR, A, iti:Reverse Loa;stcs P-cc;?S 6.Transporter 1 Company Name U.S.EPA ID Number Clean Ha;oors Environmental Services ne 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 1021 Berryessa Read C A D 0 5 9 4 9 4 3 1 C San Jose,CA 951:33 Facility's Phone: (408) 441-0982 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WtNol. 01IJ11A50,VVAcSTEAEROSOLS,2.1,1]O(IE SJMITEO4i�ANT1TY 0071 343 x 0 C i D F 0 0 0 G fo U 2.UN1993,WASTE FLAMMABLE LIQUIDS,N.O.S.,(TORCH FiJEL, DCO. 343 Pc MOLEUM DISTILLATES),3,r'''G I! 0 0 1 D F 0 0 0 2 E P 3.U10285WASTE CORROSIVE UQL'IID,AC10.'C,ORGANIC, D002 2243 X N.O.S.,(LACTIC ACID),8,PG 11 0 0 1 D F 0 0 0 0 t P 4.NON RCRA HAZARDOUS WAS'E LIQUICS,(DETERGENT, 343 SHAMPOO&CORIDITIONERS),NJA,NONE,NONE 0 0 1 D F 0 0 0 7 C P 14.Special Handling Instructions and Additional Information 1. LCCRQ LP1xSDP 3. LCCRC I.X50P 2. LCCRD 1xSDP 4. LCCRN 1x'.,f)0P lrWr?15J1773577 FLErT#4421015 LP#TARGET 0-21 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, marked and labeledtplacarded,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 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. Gener ofy erors Printed/Typed Name Signature Month Day Year 0 2 0 8 0 8 16.Intemalion nal Ship ii- E3importto U.S. 0]Export from U.S. P of entry/exit: Transporter signature for exports onl Date leaving U.S.: L O� 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O Sean Sp;tzer 021 G 8 168 Z Transporter 2 Printedriyped Name 3ignature Month Day Year r- 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Allemate Facility(or Generator) U.S.EPA ID Number J_ V Q LL Facilitys Phone: C3 18c.Signature of Altemate Facility(or Generator) Month Day Year Q Z N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1. iW 2. /W 3. � `W 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest exceplas noted in Item 18a Prm ypedName Signature Month DaY Yea f EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACIUTY T 9f4 ION STATE(IF REQUIRED) Chan Harbors has the anoropnate perrrbts for and Wii aci-ont tho-i-0 me Renertor is sniopinQ. 10288.1587 - _