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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 6617 -0172 PPW ID-1/10r21MA0 Form Approved.OMB No.2050-0039 q UNIFORM HAZARDOUS I1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A D 9 8 2 4 8 5 3 5 1 ` �498.3719 001834326 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Cal Trans District 10 845 E Pine Street Lodi, CA 95240 Generator's Phone: M4€3"30M 6.Transporter 1 Company Name U.S.EPA ID Number Clean Harbors Environmental Services Inc M A D 0 3 9 3 2 2 2 5 0 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Na a and Site,Addres5s, U.S.EPA ID Number dean Har�ora Qr nlltffi6 LL I IBM NOfth Apb&Roatl U T D 9 9 1 5 5 3 17 7 Orssrtwille,1840'" Facility's Phone: 801) 323-81 OD .79b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number.. 10.Containers 11.Total 12 Unit HM and Packing Group(if any)) No. Type Quantity Wt No 13.Waste Codes NONE,NON RCRA HAZARDOUS WASTE LIOU108,ILATEX 291 o PAINT,WATER) t9wo _ a = wr�s -.S6I'li Sofloc DF oto YO _. bit I-TJI f 4yp"lorccl,:Sol v,-1W-n r �� C II Iiv2 -00 OZ, X ®t?l jDF 601)Yv f 4. 14.Special Handling Instructions and Additional Information 1 CH2334Qa �i', 5'J CA 5.5 ;0t2-33377 i � 35 t"06 4,J ili,27-s 06 2, 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 labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipmen;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. Generator's/Offeror's Printed/Typed Name q,ature Month Day ear J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name ig��, Month Day Year I I/91 aTransporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U a LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z r, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/I yped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. HSIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) C4ftfi Marpors has the ante Perm for and win accept the waste the genermtorfs shipping.