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SSt. SK, SHIP# ?23419218 <br />0061929893 K3 <br />Fmmn Annmved. OMB No. 2050-0039 <br />Please <br />pont or type. (roan aesyneu <br />UNIFORM HAZARDOUS <br />lm use ull onra t -k—v vp—,-m.r <br />1. Generates ID Number <br />CAL.000344394 <br />2 P 1 ot <br />ar <br />E ry P <br />. <br />4. Manliest Track Number <br />61 2 9 8 9 SKS <br />WASTE MANIFEST <br />5. Genersi Name and Maung Address Generetds Site Address (Adherent Nan mailing address) <br />Fergldsan <br />530 PDrt Of Stockton St <br />STOCKTON CA 95203-4540 <br />Generators Phone 209-993-5323 <br />U.S. EPA ID Number <br />6�1���`"E�SYSTFM5 INC TXRM00812 15 <br />7. T�nsporer 2 Company Name U.S. FPA ID Number <br />CLEAN HARBORS FNVIRONMFNTAL SVC INC. MAD039322250 <br />6.Designated Facity Name and SineAddress CLEAN HARBORS SAN JUSE U.S. EPA ID Number <br />1021 BERRYLSSA ROAD <br />SAN JOSE , CA 9`133 <br />CAD059494310 <br />40H -44t-0962 <br />Fad Phone. <br />93. <br />9D. U.S. DOT Description (hdudirg Proper Shipping Name, Hazard Class, 10 Number, <br />'0, Containers <br />11. Tau. <br />'•2. Urn <br />13. Waste Codes <br />HM <br />and Packing Group If any)) <br />Nb. <br />Type <br />Quantity <br />Wt Not <br />', NON-RCRA HAZARDOUS WASTE, <br />D1115 <br />(S <br />P <br />,31 <br />o <br />Q <br />LIt7l1�IDS (5ODIUt4 TETRABORATE <br />I <br />DECAHYRATE), ttM <br />LU <br />2. <br />LU <br />(7 <br />3. <br />4. <br />Ek&lxfiowi EAddlhwlai <br />14, Spa4al Hendlln and lnfamason TSD:SJ 7477B7E,9 FE:12463 CSG: <br />24 HR EMERGENCY #1-800-465-1760 (SK / TFI) <br />AS "AGENT -FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br />AUTH <br />15. GENERATOR'SiMEROR'S CERTIFICATION: I hereby declare Nat the contents Of this codgnmentare fully and aauakiy described above by Ne Proper stripping name, and ared, ed, <br />international national regulations. d export shipment and I am the Primary <br />marked and Iabeledpisarded, mid are in all respects in proper conduon for transport according to applicable and governmental <br />Exporter. I certify Nal the contents of this consignment conform b the Isms of the attached EPA Acknowledgment of Consent <br />identified in 40 CFR 262.27(a) (A I am a large (jusi ganaator) or (b) (fflAm a sni quantity generator) Is true. <br />I certify that the waste mMmizabon statement <br />Signature Month Day Yea <br />Generators1011erors Pr�nted?ypad Name r <br />LO I <br />�OR�1G�EiN>l E <br />j <br />16. IMematioral Shipments ❑ Import b U.S. ❑ Export from U. Pmt of 1 <br />ZDate <br />- <br />IeaNng U.S.' <br />Transporter signature exports only). <br />W <br />of Receipt d Materiels M N Day Yea <br />UT <br />Name Signa Jay l7 <br />tTmmDorterowWgment <br />C� Year <br />z <br />/1Yped Naas Signature Monty Day <br />r <br />Ir <br />_f'P-2 V2 <br />� <br />16. Discrepancy <br />Indication Space ❑ E]Ty"'.❑ Residue ❑ Partial Rejection Full Rejection <br />I& Discrepancy DuantAy <br />Manifest Reference Number <br />U.S. FPA ID Nurnba <br />J <br />16D. Akerreta Fadfrty (a Gartaranr) <br />U <br />4 <br />FaeNC/s Phone-. Menth Day Year <br />U0 <br />16c. Signature of AnEma+e Fecldy (es Generator) <br />S <br />. s Wast R Management Metlrod Codes (i.e ,tales kr hazardous waste treatrnent, 6sposel, and recycling; eYl <br />4 <br />V5 <br />ILLI <br />V5 <br />1 2. 3_ <br />20. Gesn aclllty Owner a tar. Tication of receipt of hazardous materiels covered by Ne mntle ex az noted in Item 16a <br />Si r <br />y d UZit <br />rr ..1 T1 nccTlNeTtnIV STATF (IF REQUIRED <br />EPPA FF�� gg�7QQ ggv 9 ; p �vious eantons are oosoan, -P - , • -- <br />1)7(9::4 14 c <br />