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State of California—Environmental Protection AgenryY- .I <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions On back Of a G. Department of Toxic Substances Control <br /> Please print-or type. Form designed for use on elite(12-pikhI Sacramento,California <br /> n <br /> UNIFORM HAZARDOUS Document No. 2. Page 1 Ition in the shaded areas <br /> 1 1ro/s US EPA ID No. Manifest _ nformais not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address fY I.., .. ._ , A. State Manifest Document Number <br /> 44498859 <br /> B. Stale Generator's ID <br /> nA. Generator's Phone <br /> Q1 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> m <br /> p D. Transporter's Phone <br /> nO <br /> op 7. Transporter Z Company Nome 8. UB EPA ID Number E. State Transporter's ID(Reserved.] <br /> n, <br /> w"Q F. Transporter's Phone <br /> nu <br /> t9 - etisteo f.TjII`.Nom¢pnrl.$tte Address 10. US EPA ID Number G. Stole fpc hry's.ID <br /> QL ttl1V ,.. .. .> .. i <br /> f ss�'.RAhSFfaTC' <br /> CA 95221 H. Facility's Phone <br /> su- <br /> VQ 12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol L Waste Number <br /> _Z 442ARL)OEIB WAE4TE, i..IOUID, N 0. i_ T stale <br /> = 'i NA3082 Psi III {D,039) (ERO*i71 ) <br /> 3 G AQUEOUS BRAKE SOLUTION(& 3#/0'F=!_. EPA/Other <br /> o N 6' slate <br /> ooD E <br /> V R EPA/Other <br /> v A <br /> o T C. <br /> state <br /> car O <br /> R RECEIVED C E EPA/Other <br /> ad I <br /> G C <br /> ad d. State <br /> U JUN 2 9 2005 EPA/Other <br /> 1. Additional Descriptions for Materials Listed Above CITY O F LODI K. Handling Codes For Wastes Listed Above <br /> a. 6. <br /> w <br /> MUNICIPAL SERVICE CENTER <br /> d. <br /> Q <br /> Z 15. Spacial Handling Instructions and Additional Information <br /> z t �rkz,j �1 StJLdOEW)i:t.('t CARRIER, F,£3 NEC,ESSAFn <br /> _u I6 GENERATOR'S CERTIFICATION: I hereby declare that the contents of this coni8nment are fully ad occurately described above by proper ship ing name and are classified,Packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to app licable international and nationaPgovernment regulations.' <br /> J If I am a large quontiy 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 economical), <br /> Npracticable 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 /> and the environment;OR,if 1 am a small quantity generator,I have made a good faith effort to mi ' ize my waste generation and select the best waste management method that is <br /> W available to me and that 1 can afford. <br /> �. Printed/Typed_Nome / Signature Month Day Year <br /> J <br /> w T <br /> o, R 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/ Nome {� SignatureMonfhj Day Year <br /> w <br /> O 0 18. Transporter 2 Acknowledgement of Receipt of Materials - -' <br /> RPrinted/T ed Name <br /> w T YP Signa use Month Day Year <br /> E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> L <br /> ( 20. Facili Owner or O erator Certification o(racai t of hazardaus.r6alerialx covered '�Ib ifast axca as noted in Item 19. <br /> T T ped Name '�-- - Signature z nt Day Year <br /> �/ i� I t DO NOT WRITE O H LINE. <br /> Yellow: TSDF SENDS THI5 COPY TO GENERATOR WITHIN 30 DAYS, <br /> DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-stale, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />