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r PI ,ase print or type. (Form designed for use on elite (12-pitc. ewriter.) CM930t17P SAMAM Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number WASTE MANIFEST I C A H 1 1 1 0 0 0 8 5 7 1 (800) 40X3718 001137417 F L E 5. Generator's Name and Mailing Address Gen rgr dress (if different than mailing address) County Of San .1I{� oawjin - Tracy jcdlp ,yel}off ,�✓e pS i' +~k 1'ah� C A a Touth Tracy Boulevard ' ` P7 Tracy, CA N94 9 5 3 7 7 Generator's Phone: 209 4Iq-3A68 ATTN: Kin'1tira Andrews 6. Transporter 1 Company Name U.S. EPA ID Number Clean Harbors Eris Services Inc IM A D 0 3 9 3 2 2 2 5 0 1021 Borryessa Road San Jose, CA, 95133 Facility's Phone: (408) 441-002 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, HM and Packing Group (if any)) 1 FLAMMABLE LIQUIDS, WO.S., (THINNERS, PETRr�LEUM o DISnU-A,TES (HHV4)) , 3. UNI@93, p(3 11 'Z SOON 4. J.S. EPA ID Number C.A1)069494310 11:6p4tI:iArRtar71n' uy nes andAgQuional %ation 90#044 Fleet 0 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 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. enerator's Offeror's PrintedfTyped Name t -T H6 Prow -1 t p 7a ure on ay P e R+C�)af() rt.. WIIIIgw, c Sa n �TDaiSwfsq C0,4 -4y ��Gt. /LyL--- 06 " o 16. International Shipments F— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature for exports only): 11 Date leaZ U.S ,;,,N 17. Transporter Acknowledgment of Receipt of Matedals (M 1 113 0 01A 1 41 18. Discrepancy 18a. Discrepancy Indication SpaceQuanti y❑ T e ❑ Residue I.i n e q83 1? # v&*) lbru im i] to lwr s h i p Manifest Reference Number: 18b. Alternate Facility (or Generator) J UP a LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) a Z H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C3 20.-Designaled-Facuity{9omer-orClperatorLerbficabon of receipt of hazardous materials covered by the manifest cept as noted in Item 18a P' yped Name Si ❑ Partial Rejection U.S. EPA ID Number 4. ❑ Full Rejection 1-7 araept the fast the generator is shipping. DESbNATE01FACILITY TO GENERATOR 10. Containers 11. Total I Quantity 12. Unit Wt.Nol. 13. Waste Codes No. Type 007 .r 61.2 421 7- 11:6p4tI:iArRtar71n' uy nes andAgQuional %ation 90#044 Fleet 0 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 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. enerator's Offeror's PrintedfTyped Name t -T H6 Prow -1 t p 7a ure on ay P e R+C�)af() rt.. WIIIIgw, c Sa n �TDaiSwfsq C0,4 -4y ��Gt. /LyL--- 06 " o 16. International Shipments F— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature for exports only): 11 Date leaZ U.S ,;,,N 17. Transporter Acknowledgment of Receipt of Matedals (M 1 113 0 01A 1 41 18. Discrepancy 18a. Discrepancy Indication SpaceQuanti y❑ T e ❑ Residue I.i n e q83 1? # v&*) lbru im i] to lwr s h i p Manifest Reference Number: 18b. Alternate Facility (or Generator) J UP a LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) a Z H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C3 20.-Designaled-Facuity{9omer-orClperatorLerbficabon of receipt of hazardous materials covered by the manifest cept as noted in Item 18a P' yped Name Si ❑ Partial Rejection U.S. EPA ID Number 4. ❑ Full Rejection 1-7 araept the fast the generator is shipping. DESbNATE01FACILITY TO GENERATOR