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299742-16 Please print or type, (Form designed for use on elite (12 -pitch) typewriter.) 2564994 Form Approved. OMB No. 2050-0039 EPA Form Bi9622 (Rev. 3-05) P vcus eei are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS I. Generator ID Number 2. Pagel 1 3. Emergency Response Phone 4. ManilesGTracking Number WASTE MANIFEST CAH111001044 1 1 (877) 577-2669 00n157614 DAT 5. Generators Name and Mang Address Generator's Site Address (if drderenl than mailing address) SON 30ADVIN CO. PUILIC (ORIS - ORIM: STOCKTON FMCS SRA ]OHOUIN CO. PUBLIC MORNS DEPT/STOCKTON PHHVCF 1110 EAST HRZELTON AVENUE 7150 R.A. IRIDGEFORD STREET Generators Phone. STOCKTON CA 95211 120911111,11-30156 1 STOCKTON CA 95206 6. Transporter 1 Company Name U S. EPA ID Number 21st Century Environmental Management of California, LP CARD00210617 7. Trenspo 2C benyN me U.S EPA ID Number gA-✓«s- Ale r) ,eD0o0a50-7a 8. Designated Fadlity Name and Site Address U.S. EPA 10 Number RINECO CHRICAL INDUSTRIES, IN 1007 Vulcan Road Facia 'sPtcne: RFNTON, OR 12015 (5011 770-9099 ARD 1057870 9a 90. U.S. DOT Descdplion (indudirg Proper Shipping Name, Hazard Class, ID Number, 10. Containers H. Total 12, Unit HM ark Packing Group(if any)) Ouanury WINW. 13. Waste Coles No. Type C 1. UN1950 REIOSOLS 2.1 612 w X CF N/ Q P w 2 ON1263 POINT RELATED MATERIAL 3 P6II 612 X DM 22G1 P 3. U111253 POINT RELATED MATERIAL 3 PGII DOT -SP -11624 612 X Z CF /$0G 7 P 4, 14. Special Handing Insimctions and Additional Information (1) 151226237-00 - ER6(1261 AEROSOLS, POINTS, PE 12) 140505711-02 ERG(120) PAINT RELATED fi l (3) 140505171-02 - ER6(1201 PRINT RELATED MATERIALL WASTE IS EXEMPT HOUSEHOLD HAZARDOUS WASTE PER 40CFRAIAII- 15, GENERATOR'SIDFFEROR'SCERTIFICAMN: I hereby declare that the conlenls of this consignment are fully and accurately described above by the proper shppng name, and are classified, packaged marked and Iabeledlplacarded, and are in all respeca in proper condition for varspert according to applicable im materal aro national governmental regulabi If expos shipment and I am the Primary Exporter, I witty that the contents of this consignment conform to the berms of the attached EPAAcknow9edgment of Consent. I candy that the waste minimizabot statement identified in 40 OFR 262.27(a) (if I son a targe quantity genecalor) or (b) (if] am a small quantity generatort is true. GenerabrsrOf erors Pdnlad/ryped Name �, Signature 0 ve Month Day Year // o 13 /b 1— F 16. International Shipments to U.S. ❑Export from U.S. P enirylexit 2 re(: Transporter signatuof expols oNy)'. le le reg U.S: Mw 17. Transposer Acknowledgmel of Receipt of Materials Transporter I Printedrryped Name Signature Mon:h Day Year a co 30 Q Trans 21 -mi Mytl N pea Signature Month Day Year L« /a�/6 DisuePancY i1B. 18a. Discrepancy lMkxsim Spew ❑Quantity 11 Type ❑Residue ❑PaNal Rejection ❑FUG Rejection Manifest Referercz Number, 18b. Alternate Facdiry, (or Generator) U.S. EPA ID Number J U u Facility's Phone. w 1&. Signature of A temate Factity (w Germal Month Day Yea r a z N19. Hazardous Waste Retial Management Method Codes (i e., codes kr hazardwce waste treatment, disposal, and recycling systems) 0 1. 2. (fi ( 7. 20. ted Facility Owner or Opecet fico n receipt cfhazardous matenals covered by the manifest eeexxce}'I-(ave Med in Item l8a P '.etlR Name Lre Mann Day Year ) (e-- EPA Form Bi9622 (Rev. 3-05) P vcus eei are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)