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�'". -2$5-01 <br /> 'Please print or type.(Form designed for use on elite(12-pjtc writer.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phon 4.Manifest Tracking Number <br /> WASTE MANIFEST CARO`10102707 SKS <br /> 5.Generators Name and Mailing Address Generators Site Adargissdifferent than mailing ad mss <br /> HOLZ RUBBER COMPANY INC. <br /> 1129 S SACRAMENTO ST <br /> LODI CA 95240 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. TXR000050930 <br /> 7.Transporter 2 Company Name ,x U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> SAFETY—KLEEN SYSTEMS, INC. 000760 <br /> 6000 BOTH STREET <br /> SACRAMENTO CA 95828 <br /> Fadlity's Phone: 916-386-4913 CAOOOOO84517 <br /> 9a, 9b.U.S.DOT Description fincluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unci <br /> 13.Waste Codes <br /> HM and Packing Group(If any)) No, Type Quantity Wt.Nol. <br /> 1. <br /> c X PASTE PAINT RELATED MATERIAL,3, UN1263, OM P F003 DO01 DO18 <br /> D035 D039 212 <br /> W Z. <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1)ERO#12� i <br /> 8 TRCKN1#,0678382 0039303278 0003153217 0928 24 <br /> � ^t' <br /> 15, GEE 0 ' R'S RI I !'I here y dec areat the contents of consignment are y and acture ely escn a vey e proper shipping new,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 l am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimizaWn statement identified In 40 CFR 262.27(a)(H I am a large quantity generator)or(b)(i am a am quantitygenerator)is tru <br /> GenemWs10ftmrePhntedfryped Name _ — Signature Month Day Year <br /> A1 PM� /Lo ISZ <br /> �j 16.International Shipments <br /> 1— Import to U.S. ❑Expon from U.S. Port of entry exd: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Tran c n f Receipt of Materials <br /> Tra iter 1 Pdnted/fyped Name natum Month Day Year <br /> a <br /> N <br /> GTrans a e on Year <br /> K <br /> 18.Discrepancy .. <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑PaNa1 Rejection ❑Full Rejection <br /> L — k <br /> ? Manifest Reference Number: <br /> J <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facility's Phone. <br /> 18c.Signature of A temate Facility(or Generator) Month Day Year <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste beatment,disposal,and recycling systems) <br /> G 1. <br /> H141 <br /> 20.Designated Facility Omer or Operator Certification of receipt of hazardous materials covered by the manifest except as Wed in Item 1 a <br /> Print Name Signature Month Day Year <br /> Z,4/;?:Z/,-7— T— <br /> -PAF 0 (Rev.3-P PrevioUtirlRdiffoOs amobsoete. DESIGNATED FACILIT O G N RAT R <br /> 1)0012607 2) 3) 4) <br />