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Please print or type. (Form designed For use on elite (12 -pitch) typewriter.) Form Approved. OMB No. <br />0 50-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CAL000194471 <br />I <br />1 <br />BGG -333-9222 <br />002709588 <br />E <br />5. Generators Name and Mailing Address Generators Site Address (d in ferent Nan mailing address) <br />Central Valley Waste 1333 E_ Tiverer Rd. <br />PO 15or 241001 Lodi, Ca: 95240 <br />Lodi, Ca. 95241 <br />Generators Phone: 2nQ 111-1-i <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Advanced Chemical Transport CAR000070540 <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />CA -151 / f7hrililtZIOWSENUI SV Z <br />8, Designated Facility Name and Site Address U.S. EPA ID Number <br />Clean Harbors of San Jose, LLC (San Jose Facility) <br />1021 berryessa Road <br />San Jose, CA 95133 <br />Facilitys Phone: 408-441-0962 CAD059494310 <br />gra <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />1 <br />HM <br />and Packing Group (g any!) <br />Quantity <br />Wt/vol. <br />13. Waste Cod <br />No. <br />Type <br />1 <br />IIH1263, RQ Waste Paint, 3, PGII <br />% <br />1DIN <br />14007 <br />P <br />z <br />2. <br />w <br />cv <br />3. <br />) <br />4 <br />I <br />i <br />14. Special Handling Instructions and Addifional Information <br />1) ERG is 12B; CB'322832;CEC-401 <br />Project Humber: -4F11l9996V ev0o;2j4 <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare Nat Ne contents of this consignment are fully and accurately desaibetl above by the proper shipping name, and are classified, pac <br />marked and labekidlplawrded, 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 Prim <br />Exporter, I certify that the contents of this consignment winksm to the terms of the attached EPA Acknowledgment of Consent <br />I candy that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a smal quantity generator) is true, <br />eneretorsl <br />eros riot yName igna re on ay <br />i ear <br />` Fi O <br />O <br />J <br />16. Internationalmen s <br />❑ Import to U.S. ❑ Export from U.S. Pod of enbylext: <br />Transponder signature for exports only): Date leaving U.S.: <br />w <br />17. TransponerAchnowledgment of Receipt of Materials <br />Trans <br />Trans <br />her Printed/Typed N gnu on ay <br />Year <br />w <br />.. OIL� 6 Q <br />p4 <br />M <br />Transport <br />r 2 P'in <br />_ Name _ I ignatu on ey <br />ear <br />} <br />18. Discrepancy <br />, <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑PaReIecGon ❑ Full Roje <br />n <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. <br />J <br />EPA ID Number <br />U <br />Q <br />LL <br />Facili 's Phone: <br />w <br />18C Signature of Alternate Facility(or Generator) Monty Day <br />Year <br />r <br />Q <br />I <br />2 <br />,0—,x <br />19. Hazardous Waste Report Management Method Codes (i.e., bodes for hazardous vasa: treatment, disposal, and recycling systems) <br />3. 4. <br />t <br />20. Designated Faulity Owner or Operator: Certifi on of receipt of hazardous materials covered by the man8esl as noted in Item 18a <br />P !Typed N e 0 � SignaWr Month <br />1 <br />�r <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TOCEION STATE (IF RE <br />