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vironmental Protection Agency 138693 <br /> .,o.2050-0039:(Expires 9-30-99) See Instructions on back o� @ b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch riter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUSis not required by Federal law. <br /> WASTE MANIFEST �CIAI DI 017 1416141219101116 1 15 1 3 1 5 1 Z of <br /> 3. Generator's Name and Mailing Address A State lgrttfes#17aC?J#tt8ltf Llut <br /> x � <br /> 1029OST <br /> teetxt «S <br /> LODI, CA 95240 t �. <br /> LO 4. Generator's Phone ( 209) 333-^3500 1NWMW= CORTAMS D= is ,.. 4, <br /> N 5. Transporter 1 Company Name 6. US EPA ID NumberStat�TraAporTer's1b s r it iti a <br /> LO <br /> °° VAN WATERS � RAS INC � <br /> CI All Transpo�#ey s tf ha11�M t r <br /> N 7. Transporter 2 Company Name 8. US EPA ID Number f State Trans otter iD <br /> P P Y <br /> Q CI Al DI Q 91 21 3 0 21 41 Q F,Transporter's l'hofie <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Siete"Faicility's ID1 <br /> Zdk i dF H Factl+ty's Phone <br /> ItTH q.� _ ' ROAD, <br /> Lo 0 SOL <br /> FRED(WIA, XS 66"136 1 KI 31 DI 91810161 3131 21 51 4 <br /> 12 Containers 13. Total 14 Unit <br /> Q <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> V No. Type Quantity Wt/Vol 1 Wasfie NumLO <br /> ber <br /> za.g2 , MATERIAL <br /> (SFA 1' T TED T g <br /> = 3 L 263® PIS 11, PODS D001 Dt�3,5), <br /> � <br /> 3 G (kR 127 F) Mf � <br /> E b RQ, WASTE PAINT RELATED MATERIAL, f'.� Ato a <br /> 0 N 3, UNIZI53, ]PG 11, (RQ-100), (EPA, rOCO3 D001), � R� <br /> ao ELt 127) 0'10 kj�j DIM Ld/ PAJC3tltez �`"> <br /> v A 00 <br /> Is rW <br /> O C. <br /> P� <br /> 80 R :EPC > s � a�� <br /> Uj~ d t 'M <br /> LU <br /> ,£ <br /> 1. Add`+liana)Descriptiansfor Materials ListedAbove °°-', K. Handling Gods for Wastes Listed AbK. <br /> ove <br /> LU <br /> 77Y <br /> ce <br /> ..,*a - °',a �*r' '.� .;, <br /> .. <br /> Z 15. Special Handling Instructions and Additional Information WAR "MOPRIATE PROTWTIVSGRAR HAI% M . .7. <br /> P= EMERGMCY ACT: Ca 1-800-424-9300.-9300 T IDMIFY VAN WATERS <br /> Z ROMRS AS SHIPPER. <br /> = 11A. VA38533, 11B. GA10733-VA02 <br /> t- <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health <br /> N and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize m waste generation and select the best waste management method that is <br /> � 9 tY 9 .,.. Y 9 9 <br /> O available to me and that I can afford. <br /> } Print ped Name ;Signature 1 - Month Day Year <br /> tL T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> w p Printed ped lame , Signature .' - Month Day Year <br /> N > <br /> LUP �• C- <br /> U_ p 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature - Month Day Year <br /> LU E <br /> V) R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> 1 <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (4/97) Yellow! GENERATOR RETAINS <br /> EPA 8700-22 <br />