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V� <br /> Please print or type.(Form designed for use on eli (12-pitch)i p n ec Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C'1,4 t 0 00 Ic,IP 3%fa 60Qc 424 u.30t,_ {,_i ATi<r-r; 007884265 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> gl�AWT49N -1 ILE 9&404pdom -T 1 RIE <br /> P•O.Box W111ala C(LaStMoNT 4l14 <br /> Tlotmw4(e+ T baM <br /> Generators Phone: ?Ls7 4- <br /> .j-f- 0 U 0 kTtw�i d 9 �c 7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> FRE ENVIRONMENTAL SERVICES INC CAR000171017 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> A+v FIA BORS ENVIROtJAENTAL SERVICES INC MADW9322250 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> G HARBORS SAN JOSE LLC CAD059494310 <br /> 1 1 BERRYESSA ROAD <br /> JOSE,CA 95133 <br /> Facility's Phone: /08-441-OID& <br /> ga 9b.U.S.DOT Description(including Proper 3hipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> � 1 �`d',i ,.. . ...:.!A1'dOb3'4iYe1. e�dra�lft)-e� � f�J;• -� rI .. <br /> Qd f, ��, n'mac„ �•��y�c 6►'� r <br /> w 2 '..'t''• i4K(14'.i,,Poo 4514 S+'�itS !k/Ka.SNMfr+�S� 11 "L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Infcmation <br /> Handlers to be 4 trained and a Pipe.9o1�"C1°1�3t5r47'4�P� <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATIO : 1 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,I certify that the contents of this cons gnment conform to the terms of the attached EPAAcknowledgment of Consent. a 6herato� <br /> I certify that the waste minimization statement dentified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if l am a sm_(t,qur)is true. <br /> Generatoes/Offeror's fin ed(ryped Name- - Signature - Month Day Year <br /> 1 S /Gl <br /> 16.international Shipments <br /> F- ❑Import to U.S. ❑Export m U.S. Port of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Mater als <br /> Transporter 1 PrintedlTyped Name Sign turn Month Day Year <br /> y t__1A T12'C I �-- <br /> Z Transporter 2 Printed/Typed Name Signatuv Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quar tity ❑Type <br /> ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> F}- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> ZZ <br /> Y) 19.Hazardous Waste Report Management Method odes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> + 1 <br /> 20.Designated Facility Owner or Operator:Certifi tion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyke � 1 Li J Signature �! J - Month ay r <br /> ` EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNA#D FACILITY TO GENERATOR <br /> t <br />