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Form Approved. OMB No. 2050-0039 <br />Please <br />print or type. (Form designed for use on elite (12 -pitch) typewriter) �. Manifest Trackin Number <br />enerator ID Number 2. Page 1 of J. Emergency Response Phase O S 4 F L E <br />T" <br />UNIFORM HAZARDOUS 302 <br />WASTE MANIFEST CALOOOI94471 1 8rs5ft -9222 <br />Generators Sde Adtlress (N diRerent Than mailing address) <br />5. Generators Name and Mailing Address <br />Central Valley taste Services Inc 1333 EC�9er Rd - <br />Po non 241001 <br />Lodi; Ca_ 95241 <br />Generarors Phone: — U.S. EPA ID Number <br />6. renspoM1er 1 Company ame <br />000070540 <br />U.S. EPA ID Number <br />02 <br />7. TransporterCompany Name <br />G r (. vh wiz <br />U.S. EPA ID Number <br />8. Desgnated acility Name and Site Address <br />Clean Harbors of San Jose, LLC (San Jose Facility) <br />1021 Berryessa Road <br />San Jose, CA 95133 4 0 <br />Facili 's Phone' 411a — <br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers It. Total 12. Unit 13. Waste Codes <br />9a. No. Type OuanSty WI.Nd. <br />and Packing Group (if any)) <br />HM <br />D001 D035 343 <br />1 <br />TT21263, Taste Paint, 3, PGII, RQ (D001) I Dpi P <br />'.I <br />T <br />w <br />r <br />3. <br />4. <br />^ <br />CVOt070-y o1 <br />14. Special Handling Instructions am Addi Tonal Infomiation <br />/)TERG#128 <br />2) MQ60111111I ay-123}-��f'--i+ ti r rcr v <br />1) ERG #: 128; CH322832; CEC- �'�� (�_Y <br />CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />15.GENERA TOR'SIOFFEROR'S <br />in all respects in proper condition for transport according to applicable international and national governmental regulations. N export shipment and I am the Primary <br />marked and Iabeledplararded, and are <br />Exporter, I certify that the contents of this aetsgnment conform to the temp of the adached EPA Acknowledgment of Consent. <br />I cediy that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (1 11 am a small quantity garret is true. on ay ear <br />ig <br />�V[ator aro s nn y Name <br />I I. <br />!` <br />16tri matonal Shipments ElImport to U.S. ❑ Export from U S. Pon of entry/exit'. <br />H <br />Tran are nature fare as onl Date leavi U.S.. <br />W <br />17. TmnspaterAcknowedgment of Receipt at Materials Month Day 757 <br />1— <br />Transporter 1 Prnmd7fyped Name re <br />14 <br />O(f <br />5P <br />—� on ear <br />'1"� <br />Transporter 2 PrntedlfYped Name g <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Quantity <br />Manifest Refaenca Number. <br />U.S. EPA ID Number <br />18b. Altemate Faulity (or Generator) <br />J <br />U <br />LL <br />Facili 's Phone: Month Day Year <br />W <br />&, Sgnatum of Alternate Facility (of Generate) <br />Q <br />Z <br />19, Hazardous Waste Report Management Method Codes (I e., codes for hazardous waste treatment, disposal, and racydirg systems) <br />w <br />1 f 2. 3. 4. <br />20.Desgnated Faciliy Owner or Operator Centication of receipt of hazardous materials coveted by the manifest except as in Item 18a ay Y ear <br />Sgmnure <br />Il <br />� <br />PrinteM Name `_`L'1 -/L / <br />r �— <br />FACILITY T ESTIN III sTATE NF REOUIREDI <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED <br />