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7-185-01 <br /> ,.P ase print or tyfe.(Form designed for use on elite(12-pitc water) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number CAROOO1 O2707 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 1-800-468-1760 1 000277138 C EX <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> HOLZ RUBBER COMPANY INC. <br /> 1129 S SACRAMENTO ST <br /> LODI CA 95240 <br /> Generators Phone: 800-285-1600 <br /> 6.Tran�er 1 Com Name U.S.EPA ID Number <br /> SAFETY—KEN SYSTEMS, INC. TXR000O5O930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000760 U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO CA 95828 <br /> 916-386-4913 CA000O084517 <br /> Facilites Phone: <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(dany)) No. Type Quantity W(Nol.- <br /> Oz X ''WASTE PAINT RELATED MATERIAL,3, UN1263, DM P F003 DOO1 0018 <br /> PG T1, 3� <br /> DO35 DO39 212 <br /> z z. <br /> W <br /> c7 <br /> 3. <br /> 4. <br /> , t <br /> 14.SpecialHandling Instructions and Additional Intonation SK TRCK#11O969445 0040035235 0003133217 0944 24 <br /> 1)ERB#I?B t <br /> SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <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 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 <br /> Exporter,I certify that the contents of this consignment conform to the tenors of the atlached EPAAcknowtedgment of Consent. <br /> I ceNfy that the waste minimization statement identified in 40 CFR 26227(a)(M I am a large quantity generator)or(b)(a in a small quantity,generator)is We. <br /> GenemtorslOfferors Pdntedfryped Name Signature Month Dey Y <br /> U 2 'D <br /> 16.International Shipments J <br /> 2 ❑Importto U.S. : . El Export from U.S. Port of en xil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TrensporterAcknovdedg entof RecelpE atenals <br /> Transporter i Pnnt yped Name tura _ Month Day Year, <br /> y tb� U <br /> Transporter Prin yped Name SgnaWreMonth Day Y r <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.DiscrepancyIndication Space- ❑ a , <br /> Quantity [:]Type ❑Residue ❑Partial Rejection ❑Full Rejector <br /> Manifest Reference Number: <br /> 18b.Altemate Facility for Generator) - U.S.EPA ID Number <br /> J <br /> U <br /> ra+- Facilites Phone: <br /> WIse.Sgnature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Maltreat Codas(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 H141 z. 3. a. <br /> 20.Desgnated Facility gwMqor Operator.Certification of pt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdn yped Nam Signature ay Yeat ' <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DES NATED FACILI O GENERATOR <br /> 1)0012607 2) 3) 4) <br />