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SK HIP# 229697007 <br /> Please print or type. Farm Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of & or pcy Response Phone 4.Manifest Tracking Number SKS(� <br /> UNIFORM HAZARDOUS -t +, :a aV a ' V K V <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Addtess Generators Site Address(if different than mailing address) <br /> Min 'Island Mtaoina <br /> 115,M W Eight Mile got 2t' . �� -• <br /> :w`(�r_C iO CA r 703 <br /> Generators Phone: <br /> 6.Transp C mpary Name U.S.EPA ID Number <br /> `i T fig_; CX ROOMS 129);1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address lrLEAN HARBORS SAH JOSE <br /> U.S.EPA ID Number <br /> 102'1 DERRYESSA PiQgD <br /> 4418-44�..._�s���a <br /> `39N JOSIE C9,00594943 10 <br /> Facility's Phone'. <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 Packing Group(if any)} <br /> Na Type Quantity Wi.Nol. <br /> 2. <br /> uLI <br /> f7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD a 9,1 813487 35 K11 1.8407 <br /> '41 c MFP(4F. C,Y#800-46 --i760—CH/SK/TF1—Contract retained uY generater conn 1,15 �7 010 at<�;�tori y <br /> Ingirte,y- `rr• $ r "rQ y .?.:n ;'fid .� :rY''i:�^.. y,,. €'?„I'ar, .1 'l-,Jv..'5 . <br /> 15. GENERATOR'SIQFFEROR'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 labetedlpiacarded,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 generator)or(b)(if I am a small quantity generator)is true. <br /> rGener7ler <br /> atoeslOfferor's Printed/Typed NameSignature Month Day Year <br /> 16.International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Pori of enlrylexih <br /> Transporter signature(ter exports onYy): Date leaving U.S.; <br /> LU LU 17,Transporter Acknowledgment ofReceiptofMaterials <br /> Signature Month Day Year <br /> tE Transporter 1 PriniedlTyped Name E ' <br /> a Transporter 2 Prinledf yped Name s 1 Signature - <br /> Month Day Year <br /> a <br /> ti <br /> 18.Discrepancy <br /> i8a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection ` <br /> Manifest Reference Number: <br /> 1 Bb.Alternate Facility(or Generator) U.S.EPA!D Number <br /> U <br /> LL Facility's Phone. <br /> W cil <br /> 18c.Signature of Alternate Faity(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(I a,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1' 2' 3. 4: <br /> 20.Designated Facility Owner or Operator:Certifical on of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Farm 8700-22('Rev.12-17) Previous editions are obsolete. GENERATQR'S INITIAL COPY <br />