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ae of Caiifomia—Environmental Protection .Agency rm Approved OMB No. 2050-0039 (Expires 9-30-99) Form designed For 17. Trans orte-r I Acknowledgement of Receipt of Materials A- See Instructions on back o a p 9 Department of Toxic Substances Control ease print or type. use on elite (72 -pitch) fypewri� Month Dayp- Year Sacramento, California /� 9 f/ (,a-1 UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas Name Signature Month Day Year E is not required by Federal law. WASTE MANIFEST CAD ' $ 1 -4 5 $ 4 .7 4 8 01 9 4 of . 2. 19. Discrepancy Indication Space - 3. Generator's Name and Mailing Address- SITE: A. State Manifest Document Number - CAL TRANS, DIST 10 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. 1604 SOUTH B STREET -.G Printed/Typed Name 3 J Month Day Year PO BOX 2048 - STOCATON,. tCA:':95206 B. State Generator_'s ID 4Q�E 1"CA: 5201 ATTN: CHRIS MARTIN' 5. Transporter 1 Company Name 6. US EPA ID Number C. State ransp6rter's [Reserved.] D. Transporter's Phone 1901�11 63 Ma"Al 7. ranspor er Company ame ' - E _ I umber E: Stafe`Transporter's ID [Reseryed.) 9. Designated Facility Name and Site Address - - 10. US EPA ID Number G. State Clean HarborsEnvironmental, 1021 Berrysssa Road- H. Facili San Jose: CIL 95133 1 1 . US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) No. Type a: 1AZJMOUS-VASTE., SOLID B.O. S;r . 9, -NA- 3077-, ` G (P1f r- H40 73) E N b. WASTE : PAINT RELATED MATERIAL,- 3, 1263,. PGL .,. E pf: CH39625} A O T ` t9fASTE ` F'LADALA6LS LI UIDS N O 8 3 1993 O_ -,;1_1II, (gasoline) Ipf: CH4105I}; '' ' ' P d. ,NON RCRA; HAZARDOUS: OASTS, LIQUID, (daaol, emulsion)(pf: CH39624) 13. Total' 14. Unit Quantity I Wt/vol TWaste Number State EPA/Other . •.. - -,i n narrating i..ocies ror wastes prsrea above ,11.0 ..l Z�i1D�z;�� CH39625 CH39624 +� 15. Special Handling Instructions and Additional Information OB# 551-100 Emergency Contact:DILLARD:.ENV (925)634-6850wEAR. PROPER PROTECTIVE EQUIPMENT (PPE) 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this const nmentare fully and accurately described above by proper shipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport highwayaccording to_gpplicable international and �aiional-governmrntreguintions__- If I am a large quantity -generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that i have selected the practicable method o treatment, -storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effor^ minimize my waste ge ation and select the best waste management method that is available to me and that I can afford. r Printed/T ed Name -Signature - Month ' Day Year _W 1�S- T R 17. Trans orte-r I Acknowledgement of Receipt of Materials A- ` A Printed/Ty d Name Signature- Month Dayp- Year P /� 9 f/ (,a-1 71 0 18. Trans o er 2 Acknowledgement of Receipt of Materials TPrinted/Typed Name Signature Month Day Year E R E 19. Discrepancy Indication Space - F 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. f r Printed/Typed Name Signature Month Day Year I8022A (1/99) 1700-22 DO NOT WRITE BELOW THIS LINE. White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. To: P.O. Box 3000, Sacramento, CA 9581:2