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� � a a—VI-4c, <br />Please odnt or Woe. (Form desianed for use on elite 112-nitrhl tvnPViiHtP.r1 P„ n- ,—A nnerz mi )nrri_nn,:to <br />� v ♦w r.rcr.;ea^� vn <br />UNIFORM HAZARDOUS <br />WASTE <br />1. Generator ID Number CALt?Og3232SS <br />2. Paged of <br />3. Emergency Response Phone 4. <br />1 <br />Manifest Tracking Number <br />2090210 SKS_ <br />MANIFEST <br />1~SOO-4b8 �I?'$Q <br />0 <br />eren than mailiA VC n address) <br />5. Generator's Name and Mailing Address Generator's Siteddres AKA #�C <br />INCPO <br />190 N BROAD AY�C <br />Box 51138 17SSWEE�9 BROADWAY ST <br />ST€3CKTON CA 93203 PO BOX 5188 <br />Generator's Phone: 209-347-2600 STOCKTON - CA 93205 <br />'fArqiY°" LPL m�3YSTEM6, INC, U.S. EPA ID Number TXR 00'30130.., <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />g <br />8. Designated Facility Name and Site Address SAFETY— LEE" SYBTEM$i,INC. 0007!6() D .S. EPA ID Number;_ ._ <br />6000 BOTH STREET <br />SACRAMENTO CA t3828 <br />916-386-4913 CAOOOOQ84517 <br />Facility's Phone: <br />9a, <br />`9b: U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any))13. <br />Quantity <br />wt./Vol. <br />�y <br />1gVAST PAINT RELATED MAT RIAL, , UN1263, - <br />D" <br />Fs <br />F003 <br />0001 <br />�O01S <br />�34 <br />A03,5 <br />0039 <br />l. <br />z <br />w <br />2. <br />c� <br />3. _ <br />4. <br />,14: Spec(al Handling Instruotions andAdditional-Informatory <br />K AUTH99IZED TO RETAIN LICJENSEDSUOSEOUEW,�AFRIERS AS NECEWRY <br />15. GENERATPR!,S/OFFEROR'S CERTIFICATION, I hereby declare that a contents of this consignment are fully and aocurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper conditio for transp$irt according to applicable international and national governmental regulations. If export shipment and I am the Primary " <br />Exporter, I certify that contents of this consignment conform to the to sof eattached EPAAcknowledgment of Consent. <br />I*ify that the waste minimization statement identified in 40 CFI 62.2 (a if I am a large quantity generator) or (b) ' in a small quantity generator) is true. <br />Generator's/Offerors Printed[fype /' Signature Month 'Day Year <br />7 <br />_J <br />16 International Shipments <br />,0lmport to U:S. Export.from U.S. , . ; Pod of entry/exit: <br />a Transporter signature (for exports only): Date leaving U.S.: 4 <br />W <br />17STr1a no ment of Receipt of Materia <br />0 <br />n/A <br />Trans iter 1 PH ted/Typ Name na Montp, Da Yea ' <br />TranspoRV2 Printed/Typed Name nawre Month Day Year <br />18. Discrepancy,, <br />1Be. Discrepancy Indication Space <br />QuantityType Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />, <br />18b:Aitemate Facility, (or Generator) U.S: EPA ID Number <br />J <br />Facility's Phone: <br />C3 <br />18c. Signature of Aitemate Facility (or Generator) Month Day Year <br />z <br />a <br />�M <br />Hazardous Waste Report <br />;19. Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systeffis), <br />H1 <br />2. <br />3. <br />4, <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardou9 materials covered b u1e'manifest except as ed in Item 18a <br />Printed/T e Ne <br />y Signat � "k X Month Da Year <br />EPA Form 8700-22'(Rev.3-05f Previous editinnsara nhsnlata ...-..........r.....,..... ... _..__ . s� <br />� v ♦w r.rcr.;ea^� vn <br />