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Please print or type. Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000152025 2 800-483-3718 006959628SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) JC Trucking Inc 1415 W.Anderson St. Stockton CA,95206 Generator's Phone: 209-466-3282 r 6.Transporter 1 Company ame ? ? U.S.EPA ID Number Safety-Kleen Systems,Inc. TXR000081205 7.Transporter 2 Company Name I � y r� f1 U.S.EPA ID Number Clean Harbors Environmental Services,Inc. [ s7 J MAD039322250 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors Environmental Services,Inc. NED981723513 2247 South Highway 71 Kimball NE,69145 .p Facility's Phone: 308-235-4012 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1.UN 1263,WASTE UN 1263,WASTE PAINT,3,PG ll,3,PG II � D001 D005 D006 00 X 1 CF 700 P -�� D007 212 W 2. 3. 4, B 14.Special Handling Instructions and Additional Information Line 1:Profile:1723603; 15, GENERATOR'SIOFFEROR'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 labeled/placarded,and are in all 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 statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name signature Month Day Year SIGNATURE ON FILE SIGNATURE ON FILE 02 20 2019 -J 16.International Shipments 1.- ❑Import to U.S ❑Export from U.S. Port of entrylexit: M Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pr ntedlTyped Name Signature Month Day Year CO SIGNATURE ON FILE I SIGNATURE ON FILE I 02 I 20 ( 2019 QTransporter 2 Printedrryped Name Signature Month Day Year W jim jim 02 1 22 2019 t- 18.Discrepancy 18a,Discrepancy Indication Space FlQuantity ❑type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V La+- Facilitys Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. H040 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year TERI MIELKE TERI MIELKE 03 12 2019 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM