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/V -9k& <br />Form ADDroved. OMB No. 2050-0039 <br />Please print or type. (Form designed for use on elite (12-pncm) rypewmer.) q, —Manifest Number <br />2. Page i of 3. FJnergenry Response Phone <br />UNIFORM HAZARDOUS 1, Generator ID Number <br />1 003447059 FLE <br />. WASTE MANIFEST. CdL00019447I 1 666-333-9222 <br />Generator's ifs Address (4di nt than mailing address) <br />5. Generatoes Name and Mailing Address <br />Inc 1333 E Turner Rd. <br />Central valley waste Services <br />Lodi., Ce. a5?a?rT <br />PO b'u :11001 <br />L"di, Ca- 95241 <br />Generators Phone: -- U.S. EPA ID Numlter <br />. ransponer ompany am <br />0'0000'0540 <br />U.S. EPA ID Number <br />7, Transporter 2 Company Name <br />A+A .03f3��S'J <br />C c tr}•) / pigOONs inJ✓ S!�° resr <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Clean Harbors of San dame, TLC (San Jose Facility) <br />101 T5erryessa Road <br />San Jose, CA 95133 <br />FaPigs Phone: _ _ <br />9b. U.S. DOT Descrlptiar (including Pmper Shipping Name, Hazard Class, ID Number, 18. Containers 11. Total 12. Unit 13. Waste Codes <br />9a. No. Type Quantity WtNd. <br />HM and Packing Group (if any)) <br />1' UH1263, T.L`aste Paint, 3, PSIS, RQ (DO01) <br />P <br />OROS <br />D035 <br />343 <br />cc <br />o <br />( <br />C) OA <br />LA5-0 <br />z <br />2. <br />W <br />3. <br />14. <br />14. Spacial Handing Instructions and Additional Information <br />1) ERS :4' 128; CH322832; CEC-001 t ( iz Sig//; ER%3*12g <br />project iiumber_ CVOi235 <br />15. GENERATOR'StOFFEROWS CERTIFICATION: I hereby declare that the contents of Nis consignment are fully acs y desrnbed above by the paler shipping name, and are classified, packaged, <br />marked and labeledplacarded, and are m all respects In proper condition for sa'upat acmrdinB to applicable int a national gwemmental regulabans. R export shipment and I am Ne Primary <br />Exporter, I cuniy that the mmena of ft core gnment conform to the terms of the attached EPAAdnowledgme of <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(x) (it 1 am a large quantlly generator) I a snag quantity gsnmter) is true. <br />era � � igcaMorth Uay Year <br />16.Intemational Shipmenb ❑Neat to U.S. ❑EWdfrom U.S. Pat of enbylexit <br />2 <br />— <br />Trans rsi nature tar ex dam; '. Dale leaN U.S.: <br />W17. <br />TmnsporterArAnewledgment of Receipt at Materials <br />Month Day aar <br />F <br />a <br />TTran Pnntecillryped Name g <br />a D!o r8 to <br />-r O 4LA ear <br />Transporter 2 Pnnted(TyPed Namy gnature ay <br />18. Discrepancy <br />18x. Discrepancy Indication Space ❑ Quamity ❑ TYPa ❑ Residue ❑ Partial Rejection ❑ Full Reaction <br />Manifest Reference Number. <br />18b. A1temate Facility (a Generator) U.S. EPA ID Number <br />U <br />LL <br />Fadl 's Phone: <br />W <br />Day Year <br />18c. Signature of Alternate Facility (or Genemlor) of <br />Q <br />2 <br />N19. <br />Hazardous Waste Report Management Method Cordes (icor., codes for hazaNeus waste treatment, disposal, and reeyding systems) <br />C <br />f 4. <br />20. Designated Facility Owner or Operator. CertiAcatlon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Mm <br />PnntedrF ped`�..N Day BaYT�r <br />EPA Form 8700 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />