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Please print or type. (Form designedfor t se on.elitg (12 pitc, rites:) C,i14L17 PF osrws Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST " C A H 1 1 1 0 0 0 8 5 7 2 (OM)483-3718 001137415 F L E 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Court�v Of Sen Joaquin - Traev I g (o /; . Kq Lel }o w Aft 101 54"r -lc }e�, r C R C45?-01Sots Traev 6o1.la-Mard Tratw, GA Trov, CA %.5?''&¢ 95377 Generator's Phone: 209- 4t3ff-3005 ATTN. Kin -bra .Andrews 6. Transporter 1 Company Name U.S. EPA ID Number C.teart Harbors Env Services Inc M .A Cl 0 3 9 3 2 2 .y F 0 7. Transporter 2 Company Name U.S. EPA ID Number INOMP6 c�lasewd S�It Al n U.S. EPA ID Number 1021 Berryessal Fuad C star % 0 6 9 4 9 4 3 1 0 Sari Jose, CA, 9-5133 Facility's Phone: (408) 441-0962 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12, Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. t t] til fi ' ,�!.. r. , — fi _flwli,)f�l�(2 A! ><+tA' _CFI 0 tS12 W 2. + (9 3.FLAMMABLE SCUDS, 0R(30110; ►11.0.8., (RESINS, ADHESIVES 612 (i-iHVV)j , 4. 1, UN 1325. R3 IIs I 4. gill 1 11 v 1111111 fi. 14,Spe�ial iia�glnstiuctiotls�dAd itiogn�lln�oation��f` 1 p iitffArJ�FSri T 4F �t'fieri 0 Sp4ill 4-4istiite45 ERC -l40 So#Cil &qM Fleet# 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. enerator's/Offeror's Pdnted/Typed Nie MP rGti4welS t O F bignature Month Day---7e—ar 4/10 S"- 2 a ulb► ( 04 t4l 106 10Z" 10 —1 1 Iii. International Shipments Z ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials I 11D i(y Gtpqb 4 1 e O Tra r 1 Print ed Name ,��` i ign ure ` Mor Day Year It,V1 �L V Z Transporter 2 Print yped Name Signature Month Day Year F- 18. Discrepancy 18a Discrepancy Indication`Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑Full Resection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q Facility's Phone: LO 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z CD 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C3 1. 2. 3. 4 1 „ I 4. 20. Designated Facility `Owner or Operator: Certification of receipt of hazardous materials covered by the manifest ave t as noted in Item 18a pRf1t@d� dNagre Sign3tur .. Month Wr III U%&1Wffi*;b(RW3I:fi@ f0*0irtft omiftifteand Rohl accept the waste the generator is shipping. DE,6 NAIED FACILITY TO GENERATOR