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E PlAaRp,r4irfAvriA (Form dp.qinnAd fnr imp nn AIKA 1119-nitnhl NnAWrIfar I r:— Annmvnrl MAP Kln ')ArA MQn ern FV1 'J1Q1VU-ff-kr%t;V, ,)-V;Jj r1t;V1UUb UUMU11b dit$ WbUJIJIU. DESIGNATED FACILITY TO GENERATOR I)DO12607 2) 3) 4) UNIFORM HAZARDOUS 1 1. Generator ID Number �233 CAL3 2. Page 1 of 3. Emergency Response Phone 4. 10003 Manifest Tra,kInbNujb 156 CEX t WASTE MANIFEST I—IF100-4611-1760 5. Generator's Name and Mailing Address Generators Site Address if different than mailing address) WESTERN FARMS SVC INC CROP PRODUCTION SERVICES 1903 N BROADWAY PO Box MO 17505 N BROADWAY ST STOCKTON CA 93205 PO BOX sloe Generator's Phone: 209-347-2600 STOCKTON CA 95205 6. Transporter I Company Name U.S. EPA ID Number SAFETY--Kt.EEN SYSTEMSo INC. TXR000050930 7. Transporter 2 Company Name % U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number SAFETY—KLEEN SYSTEMS, INC. 000760 6000"SOTH STREET' SACRAMENTO CA 93828 916-386-4913 CA0000084517 Facilil f's Phone: ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type M and Packing Group (if any)) Quantity Wt.Nol. X 1 WASTE PAINT RELATEO MATERIALt3t UN1263, 0M P F 003 01 00 0018 0 9 pe IT, 36 D035 0039 212 Z 2. LU 3. 4. 14. Special Handling Instructions and Additional Information SK TRCK#111098480 0040352304 0000369976 0951 24 I)EPS#128 #1 # 24 HR EMER6F800-468-1760(SAFETY-Mi EN — 04136) 4 RI NT ig RISCY ,Tn U CARR 2 NECESSARY 15. GENERATOR'SIOFFERORIS CERTIFICATIOMA hereby declare that the 6mtehba ofthit conskgrijimientare fully and accurately desoribed 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 26227(a) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. Generatoes/Offerors PrintedTfyped Name Signature er Month Day Year + �1 zi J5 —J I— 16. International Shipments El import to U.S. ❑ Export from U.S. Port Z of entry/exit: Transporter sig Date leaving U.S.: only): W 17 — Is ��a " rter Acknowledgment of'gkqt of Mated i2Trqhspotter i Pdrited/Typed Name m f ro Mon I th Day Year Z Transporter 2 PriffMdRypa . ..... Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space E] Q uantity Type Residue Partial Rejection El Full Rejection Manifest Reference Number: 18b; Alternate Facility (or Generator) U.S. EPA ID Number LL ys Phone: Facilib Uj , 18c. Signature of Alternate Facility (or Generator) Month Day Year Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. H 3, 41 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as not in tem 18a Print Nam Signature Month Day Year A 12-17. 112, V7 ern FV1 'J1Q1VU-ff-kr%t;V, ,)-V;Jj r1t;V1UUb UUMU11b dit$ WbUJIJIU. DESIGNATED FACILITY TO GENERATOR I)DO12607 2) 3) 4)