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Please print or type. (Form designed for use on elite (12pitch)tvpewnter.) 612137291-002 SC PPW 11/18/2008 EPA Form 8700-22`j12ev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) Groan Harbors has the appropriate parmha for a�10470.08371,��, �� shiPPMB� UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 0l 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST CAL 0 0 0 2 8 0 3 9 9 2 (800) 4834 1 002200564 FL E 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Tart/ Stom T-1526 280 Spred" Ave SAME Manteca, CA 95336 Generators Phone: (209)823-9982 6. Transporter 1 Company Name U.S. EPA ID Number Chan Harbom EnvironmeMal SoMew Inc MAD 0 3 9 3 2 2 2 5 0 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Clean Harbors San lose LLC 10216err�sa Road - CAD 0 5 9 4 9 4 310 96133 San lose, CA -- - -- - Facility's Phone: (408441-0962 9a 9b. U.S. DOT Descript on (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 Total 12. Unit HM and Packing Group (if any)) Quantity WLNol. 13. Waste Codes No. Type 1. UK950, WASN AEROSOLS, 21, QUANTITY", 331 D001 o X DOTSP11306 001 DF 00090 P 2. UND98, WASH FLAMMABLE LIQUIDS, N.O.S., 331 D001 W (ETHANOL, PETROLEUM DISTILLATES), 3, PG II 001 D F 00020 P X 3. UN2984, WASTE HYDROGEN PEROXIDE, AQUEOUS 141 D001 X SOLUTIONS, 5.1, PG III 0 01 D F 00010 P 4 UN' 2902 PESTICIDES, LIQUID, 6.1 PG I� 0 01 D F 00020 P 232 331 X (DIAZ1N6N 14. Special Handling Instructions and Additional Information S066J2137291 FLEET+? 5234 1.TARGET-LCCRQ ERG#126 1X30 2.CH,329966 ERG#128 1X5 3.LCCRO ERG#140 1X5 4.CH329972 ERG#151 1X5 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable imemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 Cl 262.27(a) (if I am a large quantity generator) or (b) (if I am a sa I quantity ge for is true. Generator rocs P inted/Typed Name bignature Month Day Year tG , 11 21 08 j 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: = Transporter signature for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Pnnted(Typed Name 6ignature Month Day ear N MARC SANTIAGO III 111 21 08 Z Transporter 2PrintedlTypedName Sigrature Month Day Year 1-- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity❑ Type Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, 181b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q LL Facilitys Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q 2 19. Hazardous Waste Report Management Method Codes (i e., codes for hazardous waste treatment, disposal, and recycling systems) C 1. n l� 2. =oj�- 4.�� q14) 20. Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdp(@d/TName ra Month y a a 11 '2 `y�ped l 7- l J W EPA Form 8700-22`j12ev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) Groan Harbors has the appropriate parmha for a�10470.08371,��, �� shiPPMB�