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0 <br />Fkase print or type (Form designed for use on elite 12 -pitch) typewriter. <br />C -F-/161038' <br />Form Approved. OMB No 2050-0039 <br />EPA Form 8100222 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. 11 ID Number <br />2. Page 1 of 3. EmergencyResponse Phone <br />14. Manifest Tmcking Number <br />WASTE MANIFEST CAL000194471 <br />1 866-333-9222 <br />0 0 2 7 0 9 695 FLE <br />37P Name and Matting Address Generatofs Site Address (it different than mixing address) <br />Central Valley Waste 1333 E. Kerner Pd. <br />PO sops 241001 Lodi, Ca. 95240 <br />Lodi, Ca_ 95241 <br />Generator's Phone: Ino iii iR111 <br />ransporter omparry ante U.S. EPA ID Number <br />Advanced Cheanical Transport CAR000070540 <br />7. Tanspmer 2 Company Name U.S. EPA ID Number <br />c-c.�'1r4n� CNV <br />B. Desgnaled salify Name and ke LLS. EPA ID Numbe <br />Clean Harbors of Sm Jose, LLC (San Jose Facility) <br />1021 Derryesss Road <br />Sen Jose, CA 95133 <br />Facli sPhons: 408-441-0962 CAD059494310 <br />Ra. 9b. U.S. DOT Deealption (mdUdkg Proper Shipping Name, Hazard Class, iD Number, 10. Containem 11. Total 12. Unit <br />HM andPacldrig Group (d any)) No. Type Quantity WINoI. 13. Waste Codes <br />C <br />O <br />H <br />z <br />2. VN1263, RQ Waste Paint, 3, PGII Door D001D 335 <br />" <br />x I DA you � 3 <br />. 3, <br />4. <br />14 Handling Instructions and Addiconal Infornmew <br />2) CH322832; CEC- 901 <br />( 1 2 5 EPR- 1128 <br />Vosecc 00e'iia <br />15. GENERATOR'SIOFFEROFrSCERTIFICArDN: I hereby dedme Had the wmena of bas coraignmentarefully and accurately described above by the Proper shipping name, and am classified, packaged, <br />marked and Iaboledlplacarded, and am In a9 mspeca in Propawndipon for transport acconli g to appknaW international and national govemmental regulations. If export shipment and I am the Primary <br />Exporter, I cenfly mat the mntads of Mia consignment conform to the temu of the attached EPAAdmomledgment of Consent. <br />1 certify that the waste minimization elalemord klentifiecl in 40 CFR 262.27(8) If I am a large quanfity generator) or (b) (if I an a small quantity generator) is true. <br />ante s Igra n ay ear <br />"ev d <br />/6 <br />—r <br />i— <br />16. Intemalional Shipments ImportM U.S. <br />1:1❑Export from U.S. Port of entrylexd: <br />= <br />Trans a signature far exports wIfy Dam leaving U.S.: <br />W <br />17. TransporterAcknowiecigmem of Receipt of Malenab <br />C <br />TansWftr PTmte—dff—y*Nl so Monl1i Day ear <br />Transporter PdntedRyped Name ^ groansMonth Day Ye <br />, <br />A <br />18. Discrepancy 17-31 <br />18a. Discrepancy indication Space ❑ Quantity ❑ Type ❑ Residua ❑ Pamal Rajacaon ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generalon U.S. EPA ID Number <br />J <br />U <br />Q <br />r+- <br />Facili s Phone <br />W <br />188Signature of Alternate Faulty (or Generator) - Month Day Year <br />z <br />rn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste a talment, d(sposal, and recycling systems) <br />0 <br />3. <br />4, <br />2e Designated Facility Owner or Operator. CeN6caWn of ieceiptof hazardous matariafs covered by the manifest except as noted in Item 18a <br />PnntedRyped Name gnahue M th ay Year <br />EPA Form 8100222 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />