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Cj'.. <br />k j <br />Please print or type' (Form designed for use on elite (12-pitc ..,aewriter.) I Form Approved OMB No 2050-0039 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response hone <br />4 Manifest Tracking Number <br />C <br />000971178 <br />1 4 <br />1 <br />80i! 483-37i8 <br />r LE_ <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Central VSIIeV V`hSW SVsterrkg <br />San Josauiri Co uriv Solid Waste Dims , PO Box 1816 133: East Turner Road <br />Stockton, CA 85201 Lodi, CA 915240 <br />Generators Phone: 209 468-3068 ATTN: Ktrnbra Andrews <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Clean Harbors Env Services Inc M A D 0 3 9 3 2 2 2 5 0 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. es' a e F cilit Nage and Site Atl res U.S. EPA ID Number <br />delart ar�tors an Jose <br />1021 Berryessa Road C& D 0 5 A 4 0 4 3 1 0 <br />San Jose, CA, 9513 <br />441-0962 <br />Facility's Phone: (40137 <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1 AER0SOLS , 2.1, UIQ 19 bUr iC' l �l <br />1 <br />CL—M 0-r� <br />w <br />2 PAINT RELATED MATERIAL, (OIL-BASED PAINT) , 3; UN 1263, P a <br />612 <br />0 <br />A <br />3.FLANv MABLt SWDS, ORGANIC. N O.S., (RESINS., ADHESIVES <br />612 <br />X. <br />`til1V ) . 4, 1. liNi 1325, PG IN161 <br />1 <br />4TOltIC SOLIDS, ORGANIC, N.O.S., (METHYL CARBAMATE, <br />812 <br />X <br />PYRE"T'F RIMS (HHiI'd')t , 6.11, UN2811, PG 111 <br />in/ <br />V v <br />7 <br />i,,1.. <br />14. Special HandlingInstructions and Additional Information <br />2, CHS 1°L'R ; G ,N %Nd, CH2M3 <br />C -a a -q �w ngl2 <br />15. GEN ERATOR'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, <br />"marked and labeled/placarded, and are in all respects m 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 EPA Acknowledgment of Consent. <br />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. <br />Generators/Offerors Printed/Typed Name bignature s Month ay Year <br />16. TnWnational Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />W <br />Trans orter 1 Printed/Typed Name Signature Month ay Year <br />I1' -71a/ 1697 <br />y <br />,i�,a�rr1,6 <br />Z <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Typef j <br />❑Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />Q <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Rep6rtiv4anagern6t Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />G' <br />1. <br />2 .. <br />3. <br />4. <br />20. Desigtt6d FacilityOwner or Operator: Ceitificationiof ieceipt of hazardous materials covered by the manifest except ajoted in Item 18a <br />Pnhted/Typed Name - Signature Mon D91,_7Year <br />i % (f Q zPirli€►i PlA41k levnri v ih mnnant tha ucacta thio nanarztnr is chinrinn u4d­ D FACILITY TO GENERATOR <br />