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,SL 5K SHIP# 226540393 Illillllllllllllllllllllllllllllllll <br /> Please print or type. 0067776409 KForm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generator ID Number 2.Page of 3. me � Roe Ptet� 4.Man'rfestkinumber <br /> CA� ��14 '' I' 006,777690 SKS <br /> WASTE MANIFEST <br /> 5.Ge�gerator's Name and_Mailin,pddr- <br /> es ? Generators Site Address(if different than mailing address) <br /> FFree ca ]ruck _I_the #:,3F: <br /> SR 99 At 3ackstane Exit -- <br /> RIPON CA 95366-0000 <br /> r^_09-599-7961 <br /> Generator's p.1 <br /> to�re's�P�ho.ncnt ye: <br /> s.TrVWr'F f lSYSTEMS INC U S.EPA ID Number Tr RP0081205 <br /> f <br /> 7.Trar,EfA 2Do,�gp,y mg5 ENVIRQNMENTF7L 5�;� I U.S.EPA 1D Number <br /> LL WENS NC. MA003133 2250 <br /> 8.Designated FacilityName and Site Address CLEAN HARBORS SAN JOSE U.S.EPA iD Number <br /> 1021 FERRYESSA ROAD <br /> 408-441-0962 <br /> SAN JOSE , CA 95133 <br /> CAD059494.310 <br /> Facilitys Phone. � - <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes , <br /> W 2 NON—RCRA 11117ARDOUS WASTE, SOLID DM P 223 <br /> Q (0111- FILTERS) <br /> �t5c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information DI .;7-T .7 3737 Sl <br /> l <br /> Tst,. ��� <br /> 24H EMERGENCY#800--468-176L—CH/514/TFI—ContrAct retained by g.e ",t--A <br /> ,. r_,�-f r y atsthDri y <br /> an initial trar.sprorter to add or Substitute additional transporter, an generator'sbehalf. <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 labeledlplacarded,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, certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent, <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifl am a small qua fity generator)is We. <br /> enerao Offeror's Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipment <br /> j... - ❑Import to U.S. ❑Export from U.S. Partof entryl zit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T er 1 Printed[T ed N <br /> O YD S' ature Month Day Year <br /> ✓� ���I ern zs <br /> ort PrintedRyped Name Sign Month Day Year <br /> 18.Discrepancy - <br /> 18a.Discrepancy Indication Space E71 Quantity ❑Type ❑ j ❑Full Rejection <br /> ❑Residue Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generatoi) Month Day Year <br /> a <br /> z <br /> rn <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for azardous aste treatment,disposal,and recycling systems) <br /> LU 1, 2 3. 4. <br /> Hlql <br /> 20.Designated Facilcy 0&1Operator:Carl o of hazardous matenals covered by the manifest except aj not n Item 18a <br /> Pdntetl/Typed Name Signature on <br /> EP ous� <br /> 2W56777 —DESIGNATED FACILITY TES SYSTEM <br /> S <br />