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Please pant or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Annrnvad nhhp INC 2050 0039 — rieviouseamonsareoosolete. DESIGNATED FACILITYTO-DESTINATIONSTATE (IF REQUIRED) UNIFORM HAZARDOUS I. Generator ID Number r2 Page t of 3. Emergency Response Phone 4. Manifest haking Number w l�rsT CAL 0 0 0 2 5 3 4 4 5 1 (209) 836-9524 336 00, 3 A 5. Generators Name and Mailing Addresr Tri joK4 Ca+.P9K Generators Site Address (f afferent than mailing address d01i'l MNSEL PACIFIC COAST M.S., fNDi RIPS, INC. PACIFIC COAST M.S., INDUSTRIES, INC. 4101 N. HOLLY DRIVE 4101 N. HOLLY DRIVE TRACY, CA 95.378 TRACY, CA 9SB78 - Generators Phone:: ) 6T-9524 3,% 831 3,'-Z 6. Transporter i Company Name - U.S. EPA ID Number ROMiC ENVIRONMENTAL TECHNOLOGIES CORPORAMWAES (650) 324-1638 CAD 0 0 94 5 2 6 5 7 7. Transporter 2 Company Name. U.S. EPA ID Number S. Designated Facility Name and Sae Address - U.S. EPA IO Number ROMIC ENVIRONMENTAL TECHNOLOGIES CORPORATIONIAES C A D O 0 9 4 5 2 6 5 7 2081. Bay Road East Palo Alto, CA 94303-1315 Facility's Phone: (tk0) x241638 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Una HM and Packing Group (if any))13. Quantity WLNoI. Waste Codes No. Type of 1.UON-RCRA HAZARDOUS WASTE. LIQUID (PETROLEUM OIL) .. � � � n f\LnJ 223 w w NON-RCRA HAZARDOUS -WASTE, SOLID (ABSORBENT BOOMSIPADS, PETROLEUN.4 OIL) p - A (� 352 T11✓I iF/ 3. 4, 14, Specel Handling Instructors and Additional Intone on a 1: F4.341 03S SG: 0.900000 �r5 2: Pfl# 341034 SG: 0.900000 LJ� "C# 72093480 15. GEN ERATOWSIOFPEROR'S CER71FICA71ON: 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 l am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 20227(9) of I am a large quantity generator or (b) (f l am a small qua generator) is true. Genera rslOfierors PritedRyped Name ligmut Month Day Year UftN /7A LSA —.1 Is. Intematicnal9hlpmem❑s l Import rd U.S. ❑ Export from U.S. Port Z of ntiy xit Transporter signature (for exports only): Date leaving U.S.: w1 17. TmnsparterAcknoWedgment of Receiptof Matedals �.anspo ri Printed!! ed.Name� Signatu month Day Year O h �y `ice 4 mnsporler 2 Printed/Typed Name Signature Month `Day Year } 18. Discrepancy' . 18a. Discrepancy Indication Space El Ouantity 0 Type yp ❑Residue ❑Partial Rejection E,] Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) - - U.S. EPA ID Number J U LL . Facility's Phone: - - w 18c. Signature ofAttgmate Facility (cur Generator) Month Day Year Q . Z 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) 1' 2, 3. 4. 20. Designated Facility Owner. or Operator Certification of receipt of hazardous materials covered by the manifest except as m m fila Pdnced Typed Name Signature Month Day Year jL 10? EPA Fn— fE7n1 ao rte_.... — rieviouseamonsareoosolete. DESIGNATED FACILITYTO-DESTINATIONSTATE (IF REQUIRED)