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DIT-St. G_0 s a_a_ 22M. <br /> Please print or type.(Form designed for use on elite(12-pilch)typewriter.) 7J1879059 PPW 01/1orm Form Approved.OMB No.2050039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Traduce Number <br /> WASTE MANIFEST C A L 0 0 0 2 1 8 4 8 7 t (800)483-3718 1002066065 FLE <br /> 5.GeneraWls Name and Mailing Address Generators Site Address lif different than mailing address) <br /> Fairmont Sipn CornPany <br /> 850 South Guild Ave <br /> Lod, CA 95240 <br /> Generetas Phone: 209 355-8490 <br /> 6. ranspoll1 rompany Nam US.EPA ID Number <br /> Clean Harbors Environmental Services Inc M A D 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 81.��� t1 Far�M Na a�dJgdt Address: U.S.EPA ID Number <br /> 11.021 Berryessa Road 2 LL C A D 0 5 9 4 8 4 3 1 0 <br /> San Jose,CA,95133 <br /> Faafity's Phore: (408) 441-0982 <br /> 9a 9b.U.S.DOT Description Including Proper Shipping Name,Hazard Class.ID Number, 10.Carlo em 11.Total 12.Unit 13.waste Codes <br /> HM and Packing Group Cd any)) No. Type Quantity WtNol <br /> I.R <br /> ..0,UN 1203,WASTE PAINT RELATED MATERIAL,((PAINT, 214 D001 D035 <br /> o X ACETONE , ,PG II 0 <br /> )) 3 , 7 <br /> DooDM .P155 V F003 <br /> � l osf Fuoz <br /> z 2, <br /> w <br /> t7 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information 1 CH239945 —pr AM ER(,M28 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I he"declare that the contents of this consignment are Nlhy and accurately descrioed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplamrded,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 candy that the contents of this consignment conform M the terms of the abached EPA Acknowedgment of Consent <br /> I coney,that the mste mnirnizatlm statement iderinfied in 40 CFR 262.27(a)(if I ant a large quantity generator)a(b)If I am a small quantity generator)is true, <br /> Genendars,01fievers PrististorTyped Name na re Month Day Year <br /> 2- U <br /> .J16.International Shipments <br /> t— ❑mport to U.S. ❑Export from U.S. Pon of wItyleut <br /> Z Transporter sainature for exports only): Dwe feavi U.S: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpo ted7Typed Name Signatu on ay ear <br /> N <br /> S o 2 vY <br /> Q Transpoder2 Prthted7Typed Name bgnatum Monuff Day Year <br /> ti <br /> t18.Discrepancy <br /> I8aDiscrepancyNtlrcelpn Space ❑ Quantity ❑Type ❑Residue ❑Panel Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b,Aaemater Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Q <br /> LL Faali s Phone: <br /> Q 1&.Sig nature of Ademete Fmily(or Generator) Month Day Year <br /> Z <br /> 79.Hanmaus Waste Report Management Method Codes ga.,codes for harallous"Sat treatment,disposal,and mcydi g systems) <br /> 3 4 <br /> 20.Desgnated Fealty Darer or Operator.Certification of receipt of hazardous materials covered by the manifest excepts ted in Item 18a <br /> 1 7ped� 5g azure Mo Day Year <br /> IO <br /> t \/ tJ♦ <br /> EPA Form 8700.22(Rev.3d5) Previous editions are obsolete. 8 P� go;ED FACILITY TO DE STATE(IF REQUIRED) <br /> Clean Harbors has the appropriate perm3s for and will acrPnf tho waste the enetator i PPrr19 <br /> 10331.0483 <br />