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Plgegeprint or". (Form designed for use on elite (12-pk typewriter.) CE ►�3� Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 1I DESIGNATED FACILITY DESTINATION STATE (IF REQUIRED) 1. Generator ID Number UNIFORM HAZARDOUS 2. Page 1 of 3. Emergency Response Phone 4. Manilesl Tracking Number WASTE MANIFEST CAL00019"71 1 2X 000-705-7225 003931267 FLE 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) Cantral Valley Vast* Sarsiaes IAC 1333 IE 1umer Rd. Lodi, Ca. 95440 Generators Phone: 9119 14,47 _R411 6. Transporer I Company Nam U.S. EPA 10 Number Advaneed cbmiciaL Tzaneyoxt COR000070540 7. Transporter 2 Company Name U.S. EPA ID Number Clean 8arbors Easisaaaantal Services Ina. 1010039322250 8. Designated Facility Name and Site Address U.S. EPA ID Number Clean 8arbars of San Jose, LLC (San Jose rail d2LtT) 1021 Dexx"ssa Read San Jose, CA 95133 Fadi 's Phone: 400/41-0911$ CAD089494310 ga 9b. U.S. DOT Description (inducing Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Caries No. type HM and Packing Group (it any)) Quantity WI.Nol. 1. =1263, Vast* Paint, 3, PCII, RQ (111001) 1 D001 D035 343 = 2 , 3. , I I 4. f 14. Special Handling Instructions and Additional Information 1) E1110 #: 120; 08322032; CEC-0( Df Pr*j*at Number: CV02500 S7 i 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignor it are Polly and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to al Acable intemabonal and national governmental regulations. If export shipment and I am the Primary Exporter, l certify that the contents of this consignment conform to the terms of the attached EPA Ackr Iedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) If I am a large quantity ner tor) o (4I am a small amity generator) is true. ro s in em L rL.. on ay ear_ 6 J F_ 16. International Shipments ❑Import to U.S. ❑Export fin n'U.S. Pon of entry/exit = Transporter signature for e;iports onl : Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transyener P ntedflyped Name ^_ nor um on ay Year a Cy Gtr f�-ro 6d OG Z�' M Transporter 2 Pnntedrryped Name on ay ear rr►mak L 7 /s 18. Discrepancy I ISo. Discrepancy Indication Space ❑ Quantity ❑ Type El Residue ❑ Partial Rejection ❑ Full Rejection Mandesl Reference Number. 18b. Altemate Facility (of Generator) U.S. EPA ID Number J U Q aL Facili s Phone: W 1814 Sgna5m of Alternate Facility (or Generator) Month Day Year Q z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disix sal, and recycling systems) p 1 x/ ,W 2. 4. 20. Designated Fau.1 fy Owner or Operator Certification of receipt of hazardous materials covered by the in nifest except a ed in Item 18a Pnntedry!a sme / ,r i no Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 1I DESIGNATED FACILITY DESTINATION STATE (IF REQUIRED)