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_ess:-.ed =_e o-.e'-e 12�•1. ..ew-:e. J J �..1 Form Approved.OMB No.2050-003! <br /> Cd•a� - e 2 Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> . 'uf;'FORit I�tAZARnous <br /> 007884265WASTE MANIFEST CAS O iq JJ K <br /> Addlm Generators Site Address(d different than mailing address) <br /> MA"to 1 T 6 gRANN" TIP$ <br /> Pr0.8ex 1 86 ygoS CLAJ997f *"T iR�E <br /> std y CA,MIS-toy c(~tb�l c 4X20'7 <br /> -aXsPr e: 2v7 ?— pq 00 <br /> a-sem, .noa_, U,S.EPA ID Number <br /> FREMOL W ENVIRONMENTAL SERVICES INC CARM0171017 <br /> 7.-a-swear 2 Cc=-,, +s-r U.S.EPA ID Number <br /> CLEMI HARBORS ENVIRONMENTAL SERVICES INC MAD039322250 <br /> sears =a^r <br /> Na---e a-c S'-A.dd-es<_ U.S.EPA ID Number , <br /> CLEAN+tARBORS SAN JOSE LLC <br /> 1 oz1 SMIRL MAROAD CADQ59484310 <br /> SEW JOSE,CA 95133 <br /> 408-441-0962 <br /> Z J.S Y3- (rda6ng P- p � ippirg N." H.,-d Gass IC Nur.be•. 10.Containers <br /> 1.y arc�adorr Gnu �aro; 13.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity <br /> WI <br /> No. <br /> o eel bl"It)fie, <br /> � zM• µ RSTE �NOC)5�s1l+wt�S <br /> LD , D M 150 � 417 <br /> I- <br /> i <br /> Serra airy x--c075 and AMft* <br /> c- !t+r Gia!the <br /> rets declare =t8ft of tt85=ISO rt>erlt are fully and accurately desc bed above by bre gropertam <br /> shipping,fe 4e sat f, �Cairod <br /> 810 are r a!reser d wrdtion for transport accv>fi g to appfcaWe internatiaral and nationalgovernmental regulations.H eir3tt phrpmeld sndtryi <br /> e �> r`y r x ter-ss d the attached EPA Ad7cmedgment of Consent_ _ <br /> -a.'e'er-VW-CM 0r Ste rr k CFR 262-27,.a)(d l am a large gyantity generator)or(b)CAI am a erne! lor)is true. <br /> -me--r_:s:,e^-s •,-.'wd r <br /> . � Signrati,Te Ma#i' y Year <br /> 2 0 N <br /> L--,'E,.l S. Port of entry/wdi: <br /> sigaue;tr epors orvyt Date leaving U.S.: <br /> w <br /> 17_Tra scrter A4gvmedgrnert of Raow of Maa rj* <br /> rr <br /> Tremcre- Na-ie <br /> 00 Sg Month Day Year <br /> CL <br /> rn a Z : d'E w . <br /> $igla X79 <br /> < C -r— Month Day Year <br /> ~ w TW <br /> 18a.Ds:epen Lnka5x S;aoe — <br /> Quar'S. u Type Residue <br /> ❑Partial Rejection ❑Full Rajec6on <br /> 18b Aherylc Fecry(or t W Manifest Reference Number. <br /> _+ U S,EPA ID Number <br /> U <br /> i <br /> LL Facilrtys.Phone: <br /> W 18c.S?natureofAtertiateFacnity(or Generatyi <br /> ZMonth Day Year <br /> N19.Hazardous Waste Report Management Method Codas(i.a.,codes for halardous waste treetrnert.disposal,and <br /> ow 1 2 recycling systems) <br /> 3. 4. <br /> 20.Desi3nabd F .......... <br /> ad Avner or Opeaton CetifKabor.o+eceip:of razardous materials covered try the manHesl except as noted in ttem 18a <br /> Prsted'Typed Name <br /> Signature Month <br /> Day Year <br /> PA Form 8700.22(Rev.3-05) PteykM edit m are oWote <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 990/ESOF(31 DNI SOAS ANH MAOTHHA 66fE$iVVLOLT XVA 9Z:9T TT0Z/ZZ/80 <br />