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Please print oc A-..� I%30 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAfARDOUS 1.Generator ID Number 2. age of 3.Emergency Response Phone 4.Will Ifest Tracking Number- <br /> WASTE MANIFEST y V 13 3 0 4 8 3 11. *F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Min Electronics Inc- <br /> 199 <br /> nc`d99 Frank West _ <br /> Stockton, CA 85208 ' <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Advanced Chamical Transport Inc./DBA ACTen*u CAR000070540 <br /> 7.Tra er 2rplgpany N U� EPA ID Number <br /> 17 2 <br /> 8.Designated Facility Name and Site AdcIfe§s. U.S. PAID Number <br /> Cimm Harbors of San Jose, LLC CADOS940 310 <br /> 1021Belrryessa Road <br /> San Jose., CA 85133 <br /> Facility's Phone: 408441-OM <br /> 9a 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)) No. Type Quantity Wt.Nol. <br /> 1RQ,UN1993,Waste Flailumable liquids,no.s.(PETROLEUM P � 212 [Wl I=OC-43 <br /> 0 X 1�iSTTLI.ATES,XYLENES),3,PG11 PWI) FOM <br /> Z 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Propd IVUllnber 222388 DDCWle A t D269M <br /> 1)ER13#1213; CHM4004 Alc. -1 a1 TZ <br /> . {.�, ,�►2-gin_,f�-�t .�,.�-. <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 governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 certify that the wa minimization statement identified in 40 CFR 262.27(a)(if I am a large quaptity generator)or(b)(if Ian I quantity geneZ is true. <br /> Generators/Offero) ' ed/`T d NameSignature Month Day Year <br /> X 4{J ((Orr41-1 7 /S <br /> 16.Intemafional ShipmentsLlImport to U.S. -- <br /> F Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W- 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transpor/te�Pd (Ty d Name Signature MonthDay Year <br /> -1 117It/ 17IL <br /> s Tra syprt`r2nt did Si .. nth <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuej j <br /> ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Managemynt Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. � 2. 3. 4. <br /> r <br /> 20.Designated Facility Owper or Operator:Certification of receipt of qqpWous materials covered_5ythe manifest exXJas noted in 8a <br /> PrintedfTyped Name Signa e ' <br /> / !M YI <br /> 7/ / <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. ESLIG NATE FACILITYTO GENERATOR <br />