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PIeqse print or type. (Form desig <br />Ern Form 6700-22 (Rev. run) Previous abmons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />i Generator ID Number <br />UNIFORM HAZARDOUS <br />2.P 1of <br />age <br />3.Emeren R <br />9 cy asponse Phone O, <br />Msnifast Tacking Numbs <br />WASTE MANIFEST CAL000194, <br />8 <br />866-333-9222 1 <br />003447421 FLE <br />5. Genealols Name and Mailing Address Geneats s Site Address (tamerent Than mailing address) <br />Central Valle: Waste Services Inc <br />1333 E Turner Rd. <br />Lodi, Ca. 95240 <br />Geneatoes Phone: Sea iii 5fs11 <br />6. Transporter 1 Company Nam U.S. EPA ID Number <br />Advanced Chemical Transport CAR000070540 <br />U.. E 10 <br />7. Transporter 2 Company Name v k <br />MMO <br />8. Designated Facility Name and Site Address U.S. EPAID Number <br />Clean Harbors of San Jose, LLC (San Jose Fecilit7) <br />1021 Darr"ssa Road <br />San Jose, CA 95133 <br />Fadli sPhora: 408-441-0962 CAD059494310 <br />ga <br />9b. U.S. DOT DesMption(inducINg ProperShippuq Name, Hazard Clause, ID Number, <br />10.Cortainea <br />11. Total <br />12. Unnt <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WNd. <br />13. Waste Codec <br />No <br />Type <br />1 DH1263, Waste Paint, 3, PGII, IIQ (D001) <br />D00 <br />111111135 <br />343 <br />D M <br />7S <br />P <br />= <br />2. <br />w <br />3. <br />4. <br />14. Special Handling Instruction and Additional Inbmatlan <br />1) EPG !: 128; CH322832; CEC-Q 1 ( I IS6 0f) EPG11128 <br />Project number: CV01606-03 <br />15. GENERATOR'SIOFFEROR'SCERnFICATION; I hereby deciarelhatlhemnlams Wthis consignment aafultyand accuatelydeetxibedabons bythe propershipping name, and as classifled, packaged, <br />marked and labeled7placarded, and as in all respenb in proper condition M transport aouAing to applicable International and national g6remmenal regulations. texport sNpment and I am the Primary <br />Expaner, I cedty Nat the contents of this canslgnmem 00mbrm to me terms of the athsc ed EPAAconoeletmentofConvem. <br />I certify that the vasa minknballan statement Identfied In 40 CFR 262.27(e)(d I am a Isge quarmyganeratM a(b) dIemasmal quantitygenerates) Is hue. <br />GTO 9 n 1 online Month <br />al% <br />RT �lLY. <br />O (�' .... Q'1 <br />110 <br />J <br />F <br />16. Imemabonal shipments <br />❑ low toU.S. LJ Export from U.S. Pot ofentryinat <br />Z <br />Transporter sl tun for aware onlyy. Date leaving U.S. <br />W <br />17. TanspomaAdmowledgnenl ofRemlptof Meledals <br />�T <br />Name Day e ar <br />RVI ►�q� �o � <br />Transporter <br />r 'n re <br />tV� l-�Wonm izear <br />18. Disawky <br />18a. Discrepancy Indication Space ❑ Guardty ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br />Manifest Rafeanos Number. <br />= <br />1Bh. Alternate Facility (a Generator) U.S. EPA ID Number <br />U <br />a <br />u <br />w <br />Facifi episome: <br />18c. SpgnaWre of Alternate Fealty (V Generator) Mond, Day Year <br />Q <br />z <br />y <br />19. Haxsdous Waste Report Management McN,od Codes (i.e., codes for hazaNrus waste treatment, disposal, andins 9 terra <br />9 ) <br />p <br />1. (` N <br />2. 3. <br />4. <br />20. Designated Faddty Owns or Operation. Certification of neompt of hazardous mandate covered by the manifest ex®pl as noted In ttem l Be <br />nada <br />Ern Form 6700-22 (Rev. run) Previous abmons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />