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�\k 74.z+U , +V3-3 SLIT Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1•Generator.10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �((� WASTE MANIFEST CALO00117!ClS ?.- Hi 1(! -r`I' ._L7ri_. 100887cill � S f�V 5.Generator's Name and Mailing Address Generator's Site Address(If different than mailing address) TRENCH CAMP sA �3a2S1-g6>3f Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number �--'F ET`j-YLEEN SYSTEIS INC TXR000,_iE:_- _ 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN 'HARBORS ENV SERVICES INN 8.Designated Facility Name and Site Address U.S.EPA ID Number CLEAN HARBORS SAN jOSE ' 1021 BERRYESSR ROgD SAN JOSS Facility's Phone: ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WCNoI. 1. o NON-RCRA HAZARDOUS WG:-'TE, �f LIQLdva, (OIL_, DIRT, SAND, -'` AND R DIi=SEL cUEL1 z 2. LU CD 14.Special Han I.g Instructions and Additional Information ``a � ` inJ7� t1rG� 1��,+ u EMERGENCYSBOO-4�68-1760-CtH/S I�27FI-F;ont-ract r t;irlwJ b ger, at ,,r orl =Qrs ;�ggtr, - initial transF;orter `to add cor srlbstituts ad :l.-.Z oral +-:-Z-r,sporters _Iry ger era t�,: ' 15. GENERATO(t'SfOFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorslOfferoes Printedliypeii Name Signature r - Month Day Year �Li :�UIr,� F"-rL�1;uu .li rrX_� ''•._ '�..__ '�•� �i 11 i(a —j'•161riteational Shipments El -- ❑Import to U.S. Export from U.S. Port of entry/exit: ? mTransporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedlryped Name Signature Month Day Year rl :4Fu 1�i1 `Silh 0L't;trLtiC� r 11 lio z Transporter Printed yped a�me. Signature / Month Day Year 18.Discrepancy^' J r 18a.Discrepancy Indication Space ❑ Quantity ❑T e yp El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: o 18c.Signature of Alternate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management.Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1• � � � 2. 3. 4. 20.Designated F cility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a;> Printed(fyped Name` 1 / Sign lure / Month Day Year \-�� .gip--,�� "2,.-a�L.•r/'�.�'"� .--•..''"_�— ,� r l ��` � ` 'i EP. 9/ur,haz iousediti6nsareobso,_ DES16NATED FACIL'`ITYTO GENERAl'OR