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Please print or ty�e.(Form designed for use on elite(12-pitch)typewriter.) C.i1529534 APF hol:a',.070'7'19.2 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manti Tracking Number <br /> �WASTE MANIFEST C A. 00020277 w fl 2 1800)46 -_",8 003302542 J J K <br /> 5 1.3f0 <br /> nera'o• i0f8 ?-G i re� Generator's Site Address(6 dlffarent than mailing address) <br /> 23-76W K_ter ran I ane <br /> i._Orji CA 95242 <br /> Generator's Phone: 209 .3RO-0-371 A.TTItj'Reverse Lorii5tir5 Frocesso <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Env SeMces Inc M A D 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> a. Na and Ad U.S.EPA ID Number <br /> i,"fa-dn Ht5Ar5en, <br /> 1027 S_r fasaa Poa� C D 09 a 4 '3 j 0 <br /> San Jose.CA 951183 <br /> Facilitys Phone: (40$) 441-0982 <br /> 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste.Codes <br /> and Packing Group('d any)) No. Type Quantity Wt/Vol. <br /> 1•%L;ASTSc <br /> AoOSOLS:2.1 j0-i 950njOniE IMFF-ED QUAM7TY 343 DOM <br /> 0 <br /> WE 2.j noirrr L jlr,c rlGr;¢;1)Ir hi n Q(Pr-5-nC.Inr- niQt)AT 343 <br /> X 0iBR0NuiiDE).6J,L;N26iu,ru ii - 0 0 1 D F 0 0 0 3 a P <br /> 3.WASTE HYPOCHLORITE SOLUT(ONS.S,UNi791,PG 11 131 D002 <br /> Y 0 01. 1 1) F 0 0 0 2 C P <br /> a-t,l)a.:3�( OPPCISIVE 1 IQU;D;;CIDiC,,ORGANIC.N O.S.`CITRI(.- <br /> D002 343 <br /> X AC0),G,'w4328v,PG N it a i fl � n (� n E1 ,►'� <br /> 14.Special Handling Instructions and Additional Inlornafler <br /> 1. LCCRQ LP 1x5DP 3. LCCR5 1xSDP <br /> 2. LCCRC ixiSDP d. LCCRC 1yDQ <br /> WOiS"^i1529534 FLEET#4421Cf6 LP#TARGET 0-21 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hersby declare that the contents of thb consignment are fully and accurately described above by the proper shipping name,and are dassUled,packaged, <br /> marked and labeled/placarded,and are in all respects In Pmper condition for transport according to applicable International and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Conaent. <br /> I certify that the waste minirizallon statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If t am a small quantity generator)is true. <br /> Ge s/Offeroes PZ yped Name signature <br /> Month Day Year <br /> CL 0$ j7 <br /> -� 16.Inteme al Shipments <br /> Transporter signature(for exports only): Import to U.S. ❑Export fro S. Port�=Ua <br /> L 17.Transporter Acknowledgment of Receipt of Materials Data : <br /> tj Transporter 1 Printa&Typed Name <br /> Signature <br /> L Sed?SJitZar Month Day Year <br /> Transporter 2 PrintedrTyped Name 1 0 0$ 0 7 <br /> Signature- Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity <br /> Type ❑Residue ❑Paftl Rejection ❑Full Rejection <br /> C 18b.Alternate Fadi ty(or Generator) Manifest Reference Number <br /> -� U.S.EPA ID Number <br /> ser <br /> I Fadgtys Phone: <br /> 18c.Signature of-male FaciKy(or Generator) <br /> zQ' Month Day Year <br /> 19.Hazardous <br /> v`-t-R ort Man <br /> t ep agement Mofhod Codes Q.e.,codes fur hazallous wester treaanenl,di <br /> 2. sposa(,and racytling systems) <br /> 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator I 1 1ifice6on of recslpt of hazardous materials covered <br /> Prin ped Name ex s noted N Item t8a <br /> kgnature <br /> I <br /> EpForel 8700.22(Ravy3-05) Previous adltlons ora o 'B �' nth Day Year <br /> Cear,riarbors ha-Yhpp oaorooriate oarmfsfo'and yw;ll accac,t ri,a <br /> � 'FiiP•,e�.6l+ N.t�T+'-ro oEsrr r..�-E i..- r..ae <br /> o> <br />