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SSL Si SHIP# 43fi5&B5iWY? <br /> -� 008315299SK5 <br /> Please print or type. 2 ] Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Getrerator ID Number CAL0003925952-Page 1 of 3 Er�ey �i ns 4�lanfes Tr rig r �� <br /> WASTE MANIFEST 1 1 U 199 <br /> 5.Generator's Name and Mailing Address Generators Site Address{rfdifferent than mailing address) <br /> O'Reilly # 2765 <br /> 430 Cherokee Ln 39--C-02603 <br /> LOO IGA 95240-�11211000 <br /> Generators Phoneo�pap: 09—m3'-71 S5 <br /> "�YC R f;.&aSVSTEMS INC U.S.EPA 10 Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MIRI10393�'�'c"50 <br /> 8.DesignaW Facility Name and Site Address LE HARS0R5 SAN .GCSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408-441-6962 CAD0594943 a 0 <br /> Facilito Plane: <br /> ga. 9b•U.S.DOT Description(including Proper Shlppdng Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(it any)) No. Type Quantity WGNoI. 13,Waste Ces <br /> 1"� NION—RCRA HAZARDOUS WASTE SOLID, 36 � 172 <br /> FFF (METhL DUST AND MACHINING WASTE 172), r <br /> L <br /> L7 <br /> 3. <br /> 4, <br /> t <br /> 14,Special Handling Instructions and Additional Information TSD S3 ©R 1 X4 4 CSG-. r <br /> 24H EMERGENCY#800-468-1760—CHISK/I'FI—Lontract retained by genera Ir confers a ency autherit <br /> an initial transporter to add or substitute additional tern arters an enera or' alf. <br /> 15. GENERATOR'SWFEROIrS 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 labeledfplacarded,and are in all respects in proper condition for transport giccording to applicable international and national governmental regulations.If export shipment and lame ft-nary. { <br /> Exporter,I eertrfy that the contends of this consignment conform to the terms of the attached EPA Acknowledgment of Consent- <br /> I certify that the waste minimization statement identified kr 40 CFR 282.27(a)(if I am a large quantity generator)or{b}(if I am a small quantity generator)is true. <br /> Generate rnted`lT�yped Name Sign M flay Year i i <br /> be— a n GV or'{] <br /> B.International Shipments <br /> 1:1Import to U.S. <br /> ❑Export ft.U-S. Port of entrylexit: <br /> Transporter signature[for exports only}: Date leaving U.S--: <br /> W 17.Tra rterAdmowledgment of Receipt of Materials l <br /> TraObg&r 1 PdWedrF a Signature Month Day Ye k <br /> a <br /> .� <br /> z <br /> Transporlpr 2PA d Namer <br /> Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ wantity ❑Type ❑Residue ❑Partial Rejection ❑Nil Rejedon <br /> 1 <br /> E <br /> Manifest Reference Number: � l <br /> 18b.Attemate Facility(or Generator) U.S.EPA ID Number <br /> e <br /> Facility's Phone: <br /> LLJ 18c.Signature of Altamate Facility(or Generator) Ma dh Ny Year <br /> a <br /> x �N19,Hazardous Waste Report Management Mad Codes(I.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> LU <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except askq6d in item 18a <br /> PdnUXVT Signature MonthY <br /> (.0 Z1 <br /> EPA F.�±11! 0422 IRev,]2 )1Previous editions are obsolete. LESIGNATED FACILITY T A's e-MANIFEST SYSTEM <br />