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Please print or e. Form desi ned for use on elite 12• itch typewriter.) 104630373-002 SC PPW 3/3/2011 Form Approved.OMB No.2050-0039 P YP ( 9 ( P ) YP ) PP UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Track Number WASTE MANIFEST CAL 0 0 0 3 4 7 3 3 8 (800)483-3718 0 0 5 5 7 4 8 FLE 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) MCI PO Box 725 13850 North Devries Road Chino,CA 91708 Lodi,CA 95242 Generator's Phone:(9091620-5498 ATTN-2m*Feineold 6.Transporter 1 Company Name U.S.EPA ID Number Clean Harbors ErMronm Services Inc IMAD039322250 7.Trans iter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors San Jose LL. CAD 0 5 9 4 9 4 3 1 0 1021 Berryessa Road San Jose.CA 95133 Facilts Phone: ( N 4411-0962 ga 9b.U S.DOT Description(ircluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity W1.Nol. 13.Waste Codes 1 D O 2 NON RCRA HAZARDOUS WASTE SOLIDS,(OIL,DIESEL) 352 DM 7 P bol 3 N 4. HP 17 2015 14.Special Handling Instructions and Additional Information 2.CH587346 ENVIRONMENTAL HEALTH DEPARTMENT 15. GENERATOR'S(OFFEROR'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 al respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization stateme t identified in 40 CFR 262.27(a)(if I am a large quantity generator)o (b) if generator)is true. GeneratofslOtferor's Printed/Typed Name gna on ay ear 16.International Shipments - ❑Im to U.S. ❑Export from U.S Port of entry/exit: _ ? Transporter signature for exports only) Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Mat rials Transporter 1 Prinled7Typed Name Signature Month Day ear R 12-1112— Z Transporter 2 Printed Typed ame gnature ontI ay tear H 5 k 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Aftemate Facility(or Generator) U.S.EPA ID Number J U Q Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year Q 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) o i. Ht#f— z. H141 3. a. 20.Designated Facility Owner or Operator Certrfication of receipt of hazardous materials covered by the manifest except as ted In Item 18a PrinledfTypjame � ` Signature �� Month � Year d. C /ill / EPA Form 8700-22(Rev.3-05) Previous editions re obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)