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,tate of Califorrla—Environmental Protection Agency See Instructions on back of page 6. Department of Toxic Substances Control <br /> orm,,Appro*ed OMB No.2050-0039(Expires 9-30.99) Sacramento,California <br /> leas6rint or type. Form designed For use on elite(12 pi h)type <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIiORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST <br /> P C) 0 5 � 5 0 F 2 c; !' 0 � ' 8 1 of %. <br /> A. State Manifest Document Number <br /> 3. Generator's Name and Mailing Address rr <br /> S�il'lE�CllRN CHEVROLET 4 <br /> 121CA S. CHEROKEE LANE B. State Generator's ID <br /> LODI, CA 95240 <br /> n 4. Generator's Phone ( ,09 ):33f <br /> 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> 5. Transporter 1 Company Name <br /> na. D. Transporter's Phone (11300) 752-115566'AC:TEIC COAST LACQUER4 t IJ i� ✓ 2 �t a s Ic9 <br /> 7. Transporter 2 Company Name <br /> 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> J <br /> J <br /> Q =LECA <br /> 10. US EPA ID Number G- State Facility's ID _ <br /> V Name and Site Address C A O ej 0 $ 4 0 6 <br /> QGUF�CE FEC u.� � H. facility's Phone <br /> EASTxcc+ E�L�1D� c a A d (s�) 499-7146 <br /> u CA 30023 <br /> 12. Containers 13. Total 14. Unit <br /> Q 11. USDOT Description(including Proper Ship ing Nome,Hazard Class,and ID Number) No. T pe Quantity <br /> Wt/vol I. Waste Number <br /> V State <br /> Z R_. <br /> ; EPA/Other <br /> G State 214 <br /> E 3 UN1263, �l3yi <br /> o N RQ Waste Paint Relate hI&tier*&1, 17 EPA/Other 0112101 <br /> eco E QC111 <br /> R State <br /> V A c. kms_ EPA/Other �.�. <br /> c.D. O ,-- <br /> R State <br /> wd. <br /> r EPA/Other <br /> Z <br /> W <br /> V <br /> K. Handling Codes for Wastes Listed Alcove <br /> W <br /> N J. Additional Descriptions for Materials Listed 6ove a b. Ir <br /> Z _.. ..- .r. <br /> 0 : w i <br /> v E~ "fiLhfr SLUDGE <br /> Lo + LAQUF }t_j-EltC,- C. d. <br /> LU <br /> cet k"fit EPA: F002a F003, E ,,5 <br /> Z 15. Special Handling Instructions and Addition I Information ii �w` . B} (.1P ( 329 <br /> t- GLOVES, GOGGLES & PROTECTIVE CLOTHING <br /> Z EMERGENCYGONTACTa CHE. TRE C 1-8IX6-42 4-9300 <br /> W EPG#: -Vi7 j-? --'11 B?128 <br /> t- <br /> � 16. GENERATOR'S CERTIFICATION:,,I hereby eclgre 3hatt�e contents of this consignment are.fully and accurately described above by proper shipping name and are classified,pace ', <br /> Q marked,and labeled,and are in all resp is in proper condition for transport by highw°Y according to applicable international and national government regulations. <br /> V <br /> IF I am a large quant*ty generator,I cert* that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economic <br /> CL. practicable and that lave selected the auanatble ho�ltreatment, <br /> have e ade a good faith <br /> and <br /> effort tosposal ren nim zealmy available <br /> generation'and select nimizes ethe best waresent ste umanagement method that is <br /> N and the environment,OR,if I am a small q ty generator, <br /> O available to me and that I can afford. Month Day Ye?L— <br /> Signature 1 [.1 <br /> Pr' ted/Typed Name t"\t { G <br /> Z <br /> W L" 17. Trans ortey l Acknowled ement of Recei t of Materials Month Day Year <br /> a' Prin a Typed NameLU <br /> W / Month Day Year <br /> p18. Trans orter 2 Acknowled ement of Recei t of Materials Signature <br /> 0 i Printed/T.yped Numb <br /> W E <br /> N R <br /> Q 19. Discrepancy Indication Space <br /> V <br /> IF <br /> Z A <br /> — C <br /> I <br /> ` <br /> I 20. FacilityMonth Day Year Owner or Operator Certification F race* t of hazardous materials coYered b this_manifest exce t as�ts'bTe�in Item 19. <br /> Signature • C <br /> T P'ted/Typed Name ( <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />