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Generator acknowledges that no material change has occurred efther In the chardctenstics or In the process generating theorrn Appro ed.OMB No.2O5�D0 <br /> 'lease print or type. F <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trac kiNumber <br /> WASTE MANIFEST CAL 0 0 0 41 0 6 8 2 (5001463-371$ 014952660 F L <br /> 5.Generator's Name and Mallin Address Generator's Site Address(if different than mailing address) <br /> Oak Harbor Freigl�ttLines.Inc <br /> 30i8 Loomis Rd SAME <br /> Stockton,CA 95205 <br /> Generators Phone:(20914674340 U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> Clean Harbors Environmental Services.Inc. MAD 0 3 9 3 2 2 2 5 0 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> B.Designated Fadlity Name and Site Address U.S.EPA ID Number <br /> Clean Harbors San Jose LLC CAD 0 5 9 4 9 4 310 <br /> 1021 Berrvessa Road <br /> San Jose,CA 95133 <br /> Facility's Phone: (4091441-0962 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. Quantity Wt.Nol. <br /> HM and Packing Group(if any)) No• Tye <br /> 1 RESIDUE LASTCONTAINED UN1263.PAINT RELATED 512 513 <br /> X MATERIAL.3_PG II 00 2 Tp Od <br /> W z. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 11 S Id�arrdlimJ y�t�ctions aril A jopal igfgtrpabon_tw 2 X 74 r 6 F-QF T tet' 5 1 <br /> ZUZ4�i FYGilZi7 Contract retained DY generator confers nenc <br /> srthorttr on InRlal transoorter to add or GUbStRUte addItIorial transnorters <br /> g y y y rt; m name.and are classified,packaged, <br /> 15. GENERATOF' OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are full and accurate! described above b the proper shipping <br /> marked and labeled/placarded,and are In all respects In proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAciknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)a We. Month Day Year <br /> Signature <br /> Generator'slOfferors Printed/Typed Name <br /> ( � <br /> i � p <br /> -16,Intern onal Shipments ❑Import to U.S. ❑Export from U.S. Port of enb yleA: <br /> Date leaving U.S.: <br /> ? Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> Transporter 1 Printedrryped Name /�. SiMonth <br /> 6 ZQ <br /> 0 Z�� �, t�if �"�fv S Month D� Year <br /> Fu <br /> M <br /> Signature <br /> ZQ Transporter 2 PrintedfTyped Name <br /> a <br /> t— <br /> ❑ <br /> 18.Discrepancy <br /> Residue Partial Rejection <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑ ll Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J_ <br /> V <br /> LL- FacilitysPhone: Mo>tn Day Year <br /> 13 1 Bc.Signature of Altemate Facility(or Generator) <br /> w <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,lodes for hazardous waste treatment,disposal,and recycling systems <br /> in W 2. 4 3. <br /> � 1 H 141 <br /> 20.Designated Facility Owne or rata:Ce ' bon or t of hazardous materials covered by the manifest except as m I Ba ear <br /> Signature <br /> PrintedfTyped Name L <br /> f�� �e GNATED FACILITY TO EPA's a-M FEST S STEM <br /> EPA Fo58IN1H3[�Oty� �r f$��pr� e s To end volt accept the waste the ge or Is sht yL►SC 2043202137-OOti PPW <br />