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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obsolete. - DESIGNATED FACILITY TWSTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator 10 Number <br />2. Page 1 of <br />3. EmergencyResponse Phone <br />4. Marital Tracking Number <br />003025496 FLE <br />WASTE MANIFEST CAL000194471 <br />1 <br />866-333-9222 <br />5. Generatoes Name and Mailing Address Generatofs Site Address (9 different than mailing address) <br />Central Valley Waste Services Inc 1333 E Th x Rd - <br />PO bon 241001 nodi, 171- 952en <br />Lodi, Ca- 95241 <br />Generators Phone: 9n0 91ii-Alill <br />. Transporter I Compary Nam U.S. EPA ID Number <br />Advanced Chemical Transport CAR000070540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.. EPA ID Number <br />Clean Harbors of San Jose, LLC (San Jose Facility) <br />1021 6errgessa Road <br />San Jose, CA 95133 <br />Fail' sPhone: 408-441-0962 CAD059494310 <br />Sit. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11. Total 12. Unit 13 Waste Codes <br />HM <br />and Packing Greup(if any)) No. Type Ouantly, W1No1. <br />1 IIH1263, Waste Paint, 3, PGII, RQ (D001),� D001 D035 343 <br />r1 <br />fis'1 (ice) P <br />�T l <br />✓ � <br />z <br />2. not <br />W <br />PJ <br />, —242( <br />r r <br />3. <br />r r <br />4. <br />14. Special Handling Instructions and Additional Information <br />1) ERG #_ 128; CH322832; CEC- col_ ERG111128 <br />(YS501F <br />1e�6-#�-f4b <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ani fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and lahel"filecarded, and are in all respects in proper condition for tanmporl according to applicable International and nal govemmenta regulation, If export shipment and I sm the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAckmMedgmant of Consent. <br />I certity that the waste mmimicall statement identified in 40 CFR 262.27(x) (d I am a large quantity generator) or (b) (g am a small quantify generator) Is true. <br />nevas nm a ony ear <br />f -- <br />.-a <br />i- <br />16. In nal Shipments <br />❑ Import to U.S. ❑ E Wd from U.S. Port of enbylexi .. <br />Transporter signature fa exports my): Date leaving U.S.: <br />W <br />17. TranspalerAcknrnNedgment of Receipt of Materials <br />Transporter 1 PrintediTyped Name g ay YW <br />O <br />y <br />lSignature <br />Q <br />Tan rnr 2 rimed/Typed Name ay ear <br />rzi/v <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑Partial Rejectionfec0m <br />❑ FuII Re <br />Manifest Reference Number: <br />186. Alternate Facility (a Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facifitys Phone: <br />18c. Signature of Alternate Facility far Generator) Month Day Year <br />Qw <br />It <br />2 <br />h <br />19. Hazardous Waste Report Maanaimen <br />get Method Codes (i.e., codes fforhazalloua wand aste tneabnent, disposal, arecycling systems) <br />0 <br />1 w/ ina/ <br />2. 3.- <br />1 <br />4. <br />20. Designated Facility Avner or Operator: Cergfiration of receipt of hazardous materials covered by the manifest except as not Ram las <br />Pnnled/f Name SignaNra Month Day year <br />0, <br />sza4 <br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obsolete. - DESIGNATED FACILITY TWSTINATION STATE (IF REQUIRED) <br />