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SC <br /> PW <br /> Please Tint or Form desi ned for use on elite(12-pitch)typewriter.) ���� �� � �!f i�4�`` Form Approved OMB No.2050-0039 <br /> P type. 9 { P )tYP � PP <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2. a of 3.Emergency Response Phone 4.Manifest Trackinumber <br /> WASTE MANIFEST A L 0 O 0 9 3 0 2 7 19 � €SID014$3`-37'1 ���897474 FLE <br /> 5, a ator's Naa and Maili ddressLCKU Generator's Site Address(it different than mailing address) <br /> tME <br /> Acapn,CA 95220 <br /> Generator's Phone�2091 368-92TO s <br /> fi.Transporter I Company Name U.S.EPA ID Number <br /> Clean NarbarsEnvilrn€ entaiSre�-fices,Inc. M A D Q 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name ; U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Gleet Harbors-Sate lose LLC- <br /> 1021 <br /> LQ ? C <br /> �021 Fsernessa Rem +: <br /> San lose.,(;A 95U23 <br /> Facility's Phone: (4061441-0562 <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 W1.Nol. <br /> 1ROP441CRA l•4MRMUS WASTE,LIQUIDS.MRlMYLENI�, <br /> O GLYU-00 <br /> _ 77' <br /> z 2. <br /> L <br /> 3 <br /> 4 <br /> 4 <br /> 4. e�tt� d1'n Instructions and Additionallntormation . <br /> � �S-¢�� +R!! t�14#aWt>:�frfFll�3.SdF. TlCldla€!"C V�ii�ki Ft3! .itSSfrly� 4�141d.)��4fil.d�i7f€;`.4L'�iR.g.E:4i14�v�Ftt;�+3€�it�. <br /> 15. GENERATOR'Slt7FIFEROR'S CERTIFICATION: I hereby declare that the contents of this consignrpent are fulty and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledtplacarded,and are in all respects in proper eondifton for transport according to applicable intemationat 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 EPAAcoMedgment of Consent. <br /> I Certo that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity; , erator)or(b)(it I am a small quantity generator)is true. <br /> rieratorsf4#feror's Printed/Typed Name Month Day Year <br /> -1 16.In ernational Shipments <br /> a 1-1Import to U.S. ElEzpl1R€A,im.U.S. Port of entryfexft: <br /> Transporter signature for exports onl : Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Sigrialute .� s on ay Year <br /> 0. <br /> QTransporter 2 Printed/Typed Name Signature Month Day Ye7r <br /> r� <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity Type Residue ❑Partial Rejection ❑Full Reiecficr. <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA if)Number <br /> U <br /> LL Faciii 's Phone: " <br /> W 18c.Signature of Alternate Facility(or Generator) Morth Gay Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes("e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1. 2, <br /> 20.Designated Facifrty,Owner or Operator:Cerication of reoe�ef5 zardous materials ceveredby the manifest exceptps noted m Item 1S*' % y <br /> Printed/Typed Name , 3 r Signyure { y/� Month D Yee <br /> f EPA Form 8700-22(Rev.3-05) Previous editions are 66soiete. ` DESIGNATED FACILITY/ TO GENERATOR <br />