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299738-16 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />2591950 <br />Form Approved. OMB No. 2050-0039 <br />EPA Forma (ev. -05 Prev s obsolele. <br />GNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Genemtor ID Number <br />2. Page I of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CAH I I I all104& <br />77) Vj77—:)FFiJ <br />000157613 DAT <br />5. Generators Name and Mailing Address Generators Site /Ndress (f different than mailing address) <br />SAN JUAOUIN CO. PUBLIC WORKS - ORIGIN: STOCKTON PHHWCF SRN ]MOTH CO. PUBLIC WORKS DEPT/STOCKTON PN WCF <br />1010 EAST HAZELTON AVENUE 7850 R.A. BRIDGEFORD STREET <br />Generator's Prone: T TO - n11571116 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st Century vin nPlanaapplent of Cali <br />7. Transporter y Nome //�� U.S. EPA ID Number <br />e�L e C.:4rrierr 4/ictc 00002$o7.Z <br />8. Designated Facility Name and Sha Address U.S. EPA ID Number <br />RINECO CNENICAL INDUSTRIES, IN <br />1001 Vulcan Road <br />Fall SPhone: DEMON AR 77015 (5011 719-9089 ARD91]165 87 <br />9, <br />90. U.S. DOT Desorption (including Proper Shipping Name, Hazard Gass, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packng Group (if any)) <br />Quantiy <br />WLNot. <br />1. UN1251 PRINT RELATED MATERIAL 3 PGII dot -SP -11624 <br />517 <br />x <br />J <br />CF <br />s�`' <br />P <br />0 <br />W <br />2 <br />2. <br />W <br />x <br />' '- <br />oil- <br />--FL- <br />3 <br />4. <br />14. Special Handling Instsuctions and Additional Infomation <br />(11 146505771-62 - ER6(12B1 PAINT RELATED MATER] ("' 140695"" ":'qui �rciir RcQTriv INiTERIALL WRSTE IS EXEMPT <br />HOUSEHOLD HAZARDOUS WASTE PER 400261.4b. <br />15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contents of he consignment aha hit and accurately, described above by the proper sNppng name, and am classified, packaged, <br />marked and labeledlplecarded. will are in all respects in proper anelow too transport auadig to applicable in umnabortaland national govemmental regulations. It export shipment and I am the Primary <br />Exporter, I cemy that the contenk of this consgnment conform to the Who; of the attached EPAAcknowledgmant of Consent. <br />I cony that the waste minnizalim statement identified in 40 CFR 262 27(a) (i1 I am a Inge quenely generator) a (b) (if I am a small quantity generator) is tme. <br />Generalo/YOReroes Prinfetl/Typed Name 01 O, Sgnatum Month Day Year <br />(tat !I1 30 /6 <br />-Tr --1w aa.� cr <br />—1 <br />F_ <br />16. Intematlonel Shipments <br />❑Impon to U.S. Expos from US. Part of ntrylexh <br />Z <br />Transporter slgnature(for exports only): Dale "VY414 <br />W <br />I7. Transporter MYmMedgrianl M Receipt of Materials <br />K <br />Transporter 1 PdntadRyped theme,1 Signor <br />Month Day Year <br />H <br />FF �`N S✓�— <br />I' '� <br />:= <br />Toanspw;r41rimdqyped Name Sig'ature Month Day Year <br />18. Discrepancy <br />16a. Osaepancy Indication Space ❑ Quantity ❑Type Residue ❑Partial Rajeclbn ❑Full Rejection <br />Manifest Rate.. Number: <br />18b. Alternate Facility (or Generabl) U.S. EPA ID Number <br />7 <br />U <br />rail <br />Fadhtys Phone: <br />w <br />18c. Sgrature ofallemate Facdly(or Generator) <br />Month Day Year <br />a <br />z <br />N19. <br />Harardous Waste Repan Management Method Codes (i.e., codes for hazim" waste Veetrnenl. disposal. and recycling systems) <br />G <br />1, <br />2. <br />3. <br />4. <br />20. Dep ton Facility Owrrer or Oposaitarroolical o retail 1 of hocardW s materia§ covered by the mani wed 0 Item 16a <br />1 <br />P f Name gn n Mort, Day Year <br />EPA Forma (ev. -05 Prev s obsolele. <br />GNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />