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L <br />Please print or type. (Form designed for use IM elite (12-p• miter.) U d'� V "tIDJ 1 <br />40 <br />® CEiolo <br />Forth Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. <br />EPA Form 8700-72 (Rev. 3-05) Previouseditiom are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />Generator ID Number <br />2. Page 1 of <br />3. Ematgmcy Response Plane <br />4. Man umbez <br />WASTE MANIFEST MOOO194471 <br />1 <br />866-333-9222 <br />0"0"2",",69571 7 <br />FLE <br />5. Generators Name and Malang Add" Generators Sia Address If damerent man mailing address) <br />Central Valley taste 1333 E. Turner Rd. <br />PO Dor 241001 Lodi, Co. 95240 <br />Lodi, Ca. 95241 <br />Generalora Phone: <br />6 ranspaar I wnpa?Y eons U.S. EPA ID Number <br />Advancad Chemical Transport CM000070S40 <br />7. Transporter 2 Canpany Name U.S. EPA ID Number <br />8. Designated Fadlity Name and Site Address U.S. EPA ID Number <br />Clean Harbors of San Jose, LLC (San Jose Facility) <br />1021 Derryessa Road <br />San Jose, CA 95133 <br />Faulil IsPhone: CAD059494310 <br />9a. <br />9b. U.S. DOT Desor"on @Kkdrp Proper Shipplrp Name, Hared Car, ID Number, <br />10. Contarters <br />11. Taal <br />12, Unk <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Paddng Group (dany)) <br />Quantity <br />Wt.Noi. <br />1 081263, RQ Waste Paint, 3, PGII e0col <br />D03 <br />34 <br />ga <br />x <br />JIDOOJ <br />1 <br />Eff <br />Voo <br />P <br />z <br />2. <br />Lu <br />3. <br />4. <br />14. Spedd Handling Instructions and Additional Informa w <br />1) ERG #: 128; CH322832;CEC-1901 CI.V9r, <br />Project Humber: C700306 <br />15. GENERATOR'SADFFEROR'S CERTIFICATION: 1 herebydedae that the contents dtha oveo ment ere fully anti amnalely desatbed above by the proper shipping name, and are dassitied, packaged, <br />' maned and aheled(piaosrded, and are M all leepecb In proper exam for treneDod emadkg a tematlttW end national govrnmenlal reg atom. If export shipment and I am the Primary <br />Exporter, l cw* that da oonams of this consWna t conform b the oma of the afadied EPA f Cmaan. <br />I tardy that the wave mhnkaabon sb*wt idended In 40 CFR 282.27(&) (S I am a WWguar 4 b) (S 1 am a smeti guantry generator) is true.. <br />Generatoron <br />tevicat <br />ay <br />' 'few <br />ic <br />F <br />16. Internatonal Shipments ❑importte US. ❑Export from U.S. Pon of entrylexic <br />z <br />Tranaporter sxonature ffore Date leaving U.S.: <br />w <br />17. TmnspoderA&wMedgnment of Recdµ of Mall <br />.—Mn ! <br />Day ear <br />C) <br />QTrenspo <br />2 P n yyed Name <br />?Y ear <br />F <br />18. Discrepancy <br />f8� paP3 ndma Own lJ puantlly LJ Type IJ Resitlua ❑ Paoal Rejection <br />❑ Full Roje on <br />Manifest Reference Number. <br />18b. AI[emete Feday (or GxmeraOod U. S. EPA ID Number <br />zi <br />U <br />LL <br />Facili s Phoim: <br />W <br />111c.SignaareofAltemate Fadety(Of Generator) <br />Monro Day Year <br />Q <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., mdes for hazardous waste treatment, disposal, and reryding systems) <br />1. <br />2 <br />3. <br />4. <br />20. Designated FacilityOwner or Opemkir. Cer(rfikaadon of ramal olf haazardoue materab carered by time maanifeessterxonµ as rated in Item far <br />PA�YP�N 4weax� � � <br />Month <br />� � Year <br />♦ )�W"r \� 1" <br />EPA Form 8700-72 (Rev. 3-05) Previouseditiom are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />