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lifornia—Environmental Protection Agenc <br /> ,..a. .,,..dOMBNo.2050-00391Expires9-3G�/ See Instructions on �JL of Page b. Department of Toxic Substanct <br /> Please print or type. Form designed for use on.life I s[-pitch)typewriter. Sacrament,Califomi <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Pagel I Information in Russ shaded areas <br /> WASTE MANIFEST ✓ 9 (�/ j, is not required by Federal law. <br /> of <br /> 3. Genss%'s N ft and Mailing Address A. Stab Manifest Document Number sse�y s�e..w ! <br /> Gev..ke Lodi Dodoe 21 rI M53 <br /> 1255 So. aeokMan Road <br /> O B. State Generator's ID <br /> v 4. 4m(('�ttor's Phone 1 1 tx �5a41 <br /> I. za9 :ass- 5128 1 NJ AlNJ q 3161010161615141 <br /> U5. Trans iter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> a; RONO Environmental Technologies <br /> O D. Tronsporter's Phone 6801'924-1638 <br /> O C A D U a 8 4 3 dBW t <br /> W 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> 4i s V LK.j <br /> Phone <br /> 9. Designated Facility Name and Site Address 10. U8 EPA ID Number s tD <br /> M d ROMIC Environment Technologies Cl tJ 010191415121615171 <br /> 1�Z 2061 Ela Rami <br /> 0 y one <br /> l�LL Esast. Palo Acta, CA 84;303 CAO 0 6 8 4 3 2 6 8 `7 '90/324-1698 <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Co13. Total 14. Unit <br /> U No. OaanBty Wt/Vd L Waste Number <br /> Z a. State <br /> Other regulated substances, liquid N.O.S.g U3 <br /> 3 G NA 30®12, P0i11, RQ, Contains Ethylene f ". 1 Q 0 9 (N <br /> EPA/Other <br /> E b. sae <br /> 0 <br /> N <br /> m E <br /> a R EPA/Other <br /> v A <br /> o T stote <br /> mO <br /> R EPA/Other <br /> Fd. State <br /> Z <br /> W <br /> U EPA/Olher <br /> w <br /> m <br /> J. A lional Descriptions for Materials Listed Above K. mg bort <br /> Codes far Wastes Listed A <br /> o I aoste EMylene Glycol a. 1 Is. <br /> a <br /> W <br /> (Antifreeze) <br /> Q <br /> Z 15. Specht Handling Instructions and Additional Information <br /> UltlVes and Protective Clothing Emergency Response ishan 8001766.4248 <br /> z ROMIG Prefile 8201111 Emergency Response Guide Doak W1 <br /> W_ <br /> H <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this<onsignment are fully and occorotely described above by proper shipping name and are classified,Packed, <br /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according ro applicable international and national government regulations. <br /> If I am a large gaanliy generator,I certify that have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economics <br /> ypracticable and that I have selected the practicable method o1 treatment,storage,or disposal currently available to me which minimizes the present and Furore threat to human hec <br /> and the environment;OR,if I am a small quantity generator,I have made a good kith effort so minimize my waste generation and select the best waste management method Ind <br /> 0 available to me and that I can aFord. <br /> )r inled/Typed Name Si naNre 77—r*? <br /> anlh" 'Do y 7 <br /> V <br /> '' r <br /> 6 1 17. Transporter 1 Acknowled amen'of Receipt of Materials <br /> W 4 Printed/Typed Name Signature Month Day <br /> p,t F ,✓!� JV �r r1 1 r-''1 f J,� r C% r i r'� J L. <br /> W 0 18. Trans r 2 Acknowled ement of R..I t of Materials <br /> O T Printed/Typed Nome §ignatursMontl Day <br /> H E <br /> Q R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> _ p <br /> C <br /> L <br /> 1 20. Facility Owner or operator CerBRcation of receipt of hazardous materials covered by this manifest..ce t as noted in Item 19. <br /> T Printed/Typed Nome Signature Month Day <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> EPA 8700-22 fellow REl'AR <br />