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Please annror type. (Form designed for use nn elita (19-ni ewriteri- YGJINI�F11 CN fMVILI I I I V l7Cl\CIViI VR Clean Harbors ham the appropriate perrab for and Will accept the waste the generator is shipping: ..--- --- -.. - -_ ,._ r.._ r_......,..� _,131 .. a ruunnppruveu. uNltl N0. zu0u-uuJy UNIFORM HAZARDOUS 1. Generator ID Number 7.1rage 1 of 3,"Emergency Respons aanifesstTrraccking Number WASTE MANIFEST 0010971184 9 F L E 5. Generator's Name and Mailing A res Gane a o s ite dress i different than mailing address) Central Valley ftm SVsterm Sail Joaquin County 'Solid V%ste Divis , PO Box 1810 1333 East Turner Road Stockton, CA 95201 Lodi, CA 95240 Generators Phone: ATTN: Kir l Andrem 5. Transporter 1 Company Name U.S. EPA ID Number Clean Ha f ors Env Services Inc bet ,A D 0 3 9 3 2 2 2 5 0 7. Transporter 2 Company Name U.S. EPA ID Number _ 5"e- rte ,� r U/P Designated Facility Name and Site Address ` U.S. EPA ID Number 1%0f O_A44 Facility's Phone: 6P �?P*4111411W 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type 0 1 FLA!>RMABLE LIQUIDS, N.C3.S., (THINNERS, PETRoLEum 812 X FAS_nLLATES (HHV )) , 3, UN 1993, PC9 Ii A� "! d io Z LU 2 NON RCRA HAZARDOUS WASTE SO DS, (OIL FILTERS f11 4114 )j, 612 I NONE '-NON RCRA HA.'7ARDOUS V A.•^_+TI~ SOUDS, ('EIVi!'TY CONTAINER t� 612 FOR RECYCLE). NONE t o 4201 % '00 14. Special Handling Instructions and Additional Information 1 r� 3• CH21 15. GENERATOR'S/OFFEROR'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 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. enerators/Offerors PrintedlTyped Name signature Month Day Year 1 F 16. In rnational Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter si nature for exports only): Date leaving U.S.: LW LW 17. Transporter Acknowledgment of Receipt of Materials 00 Trans orter/1Pnntteedd/TypedName �yy / // %✓ �j Signature K Month Day Year rL'Day Z Tran rter 2 Printed/Typeff piame f Signature ! MonthY Year -77 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type yp El Residue ' ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U ' Q aL i Facility's Phone: w 1 . Sitature 0 teme" ltltq or�'enerat0 m r Month Day Year Z _ 1 N19. Hazardous Waste Report} Management' Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) D 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the a ifest except as noted in Item 18a dgyped N e, ture Month Day Year EPA Form 8700-22 (Rev. 3-051 Previous editions are ohsolete- r%Ee #'•.IA-rrM r.n11 1n T^ ..�..r.,., YGJINI�F11 CN fMVILI I I I V l7Cl\CIViI VR Clean Harbors ham the appropriate perrab for and Will accept the waste the generator is shipping: