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0 Ds ass 4z20 <br />`'Plimse pdd'l or type. (Form desiqned for use on elite 112-oitchl tvoewritef.l Fnr,r, Annrn%nd 1RAG Mn onr n_nmG <br />EFA Form dfui (Hev. 3-uo) t•revlous eddlons are obsolete. DESIGNATED FACILITY V DES ATION STATE QF RE049ED) <br />UNIFORM HAZARDOUS t. Generator Ip Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CALOOG194471 <br />1 <br />866-333-92221 <br />002260997 FLE <br />5. Generator's Name and Mailing Address Generator's Site Address (it different Nan mailing address) <br />Central Valle= taste 1333 E_ Turner Rd. <br />PO Dor 241001 Lodi, Ca. 95240 <br />Lodi, Ca_ 95241 <br />Generators Phone: 2f10 Iii 4611 i. <br />6. Transporter 1 Company Name U.S. EPA 10 Number <br />Aderaaced Chemical Transport CAR000070540 <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facili ame and Ste Address umber <br />Clean Harbors of San Jose, LLC (San Jose Facility) <br />1021 Derryessa Road <br />San Jose, CA 95133 <br />Facility's Phone: Phone: 408 -441-0962 CAD059494310 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />72. Unit <br />HM <br />and Packing Group if any)) <br />Quantity <br />WLNGI. <br />13. Waste Codes <br />No, <br />Type <br />1, RQ Waste Paint, 3, OW1263, PGII (0001) <br />D00 4 <br />D03 <br />1.39 <br />t <br />= <br />2. <br />LIJ <br />3. <br />r <br />d <br />4. <br />14, Special Handling Instructions and Additional Information <br />1) ERG /: 128; CH322832;CEC- 601 C(rcSS> CFG-gp� <br />Project lumber: CV00230-01 <br />15. GENERATOR'S/OFFEROR'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, packs <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 terms of the attached EPA Acknowledgment of Consent. <br />' <br />I certify that the waste minimization statement identified in 40 CFR 262.27(e) if I am a large quantity genemlor) or (b) (A I am a small quantity generator) is true.Ge <br />nemIo m `s nnte yp ame /� tt� igna re Q <br />Month ay ear <br />F-PLJ JOA <br />-J <br />16. International Shipments <br />❑Import to US. ❑ <br />1— <br />Export fro. LLS. Port ofentrylexit <br />— <br />Trans oder signature for exports only): Date leaving US.: <br />w <br />17. TranspoderAcknowledgmentof Receiptof Materials <br />Tran ort <br />1 PdntedfTypedp�/ me/ igna re' Month Day Year <br />y' <br />©2 2 <br />Transporter 2 Pdnledrryped Name Month Day <br />C <br />f— <br />year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fu1I Rejectikn <br />Manifest Reference Number: <br />181h. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />a <br />at <br />Facility's Phone: <br />W <br />18c. Signature ofAtemate Facility(or Generator) Month Day .ear <br />0 <br />h19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />L <br />2. <br />Desgnated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest pt as noted in Item 18a <br />l20. <br />P yped' i Signet re MS <br />y0171 <br />'p <br />Y,q <br />EFA Form dfui (Hev. 3-uo) t•revlous eddlons are obsolete. DESIGNATED FACILITY V DES ATION STATE QF RE049ED) <br />