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uneww,em..nmacnan rAgency <br /> Form Approved OMB No.2050-0039(Expires 9-30-991 See Instructions on back O <br /> Please prink or type. Form de jgned fon�se oanfile[12-pifcl Tiler. E 6• Department of Toxic Substances Control <br /> Sacramento,California <br /> UNIFORM HAZARDOUS i• Generator s US EPA ID No. Manifest Document No. a <br /> Information in the shaded areas <br /> WASTE MANIFEST C A 1) 9 8 ], IS '7 � 9 `1 � � is not required by Federal law. <br /> 3. Generator's Name aqd 141a-Ii ng Addre}s <br /> lri�"111 ply gry I � J ? .1 <br /> A. StaNumber <br /> V25 WOvy k1tr" 2388194.1 <br /> Stbekttow, rA 9a2lt)a <br /> 4. Generator's Phone4204lbcW4-4G8"LR B. Stale Generator's ID <br /> CV 5. Transporter 1 Company Name b. US EPA IU Number <br /> Co <br /> I C)MIC; E-yjVit`t7rl�tfl6LntaE d` lSrit81¢F}�t 3 C. StoYe Transparler's ID[ eserved,) <br /> 0 <br /> D. Tramporler's Phone <br /> C. D 0 $ 6 <br /> 5 2 6 1 7 501.124.1630 <br /> CP 7, Transporter 2 Company Name 8. US EPA ID Number <br /> E. State Tronsporier's ID[ eserved,) <br /> r J <br /> w � <br /> 4QJ F. Transporter's Phone <br /> 9. Designated Facility Nome and Site Address <br /> $�OMlti Envi1Y7'r16 emit'Te"t"�lnisloglLft 10, US EPA ID Num6er G. State Fed ity's ID <br /> 10 W o ;El t1 iy Road AlD +D ; 6 2 6 l <br /> H. Facility's Phone <br /> E&A Palo Alto CA 94303 CAl D 0 0 9L415 2 6 5 7 650132 r163 <br /> V11. US DOT Dascriplion(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. TalalMZ <br /> 14. Unit <br /> a• No. T pe Quantity W401 I. Waste Num her <br /> t Vll�alr reguiaterl subb**tances, tigUid WO.S•9 1 State <br /> E NA 3062, edit, RQ, Coontains Ethylene Glycol • <br /> - I- F EPA/Olber <br /> N N b. � <br /> NONE <br /> OD E ware <br /> -4 R <br /> A EPA/Other <br /> o T <br /> Q © Slate <br /> R <br /> of EPA/Other <br /> LU d. <br /> Z <br /> LU $rate <br /> U <br /> LU EPA/Other <br /> Z <br /> J. Additional Descriptions For Listed Above <br /> K. Handling Codes for Wasles Listed Above <br /> fil ':1;; 1y6 :kllyrap 01 b. <br /> � aellree <br /> Z <br /> © 15, Special Handling Instrudians and Additional Information - _ <br /> a cloves and Protec#iun Clothing Emergency Rpoi kr�tj;�ae: F"Itfrya�e �P�Itl1�"6?}c�..,±?4�t <br /> Uj Z ROM W Profile I I <br /> Emergency Respo"s" Guida Book #V1 <br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately.described 06"by proper shipping name and are classified,packed, <br /> U marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quanlity generator,r certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be economically <br /> practicahle and that I Piave selected the radicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human hsoZ <br /> and the environment;OR,if I am o small quantity generator,f hove made a good faith effor+'to minimize my waste generation and select the best waste management mothad that is <br /> availo6le to me and that I car.afford. <br /> } Print d/Typ:7� Si nature � + Monthll <br /> Day Year <br /> w4.W_. -1 ,+ s .. �.'/��,..w� <br /> u.s 1 - <br /> (} A 17. Trans orler 1 Acknowled ement, ecai t of Materials <br /> w A Printed/Typed ppp���''ame <br /> Uj S � Sig re r �. <br /> W f ^t Day Year <br /> Ll- @ 18. Trans orler 2 Acknowled ement of I ' l of Materials ✓� � f �]( <br /> Q A <br /> ) 17101 <br /> E <br /> Printed/Typed Name <br /> W E �i� <br /> R Month Day Year <br /> V F 19. Discrepancy Indication Space <br /> Z _ <br /> A <br /> C <br /> I <br /> L <br /> f 20. facility Owner or—O aralor Certification of receipt of hazardous materials covered by this manifest exce r as noted in Item 19. <br /> T Printed/Typed Name <br /> y Signature <br /> Manch Day Year 1 <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 80222 JI/991 <br /> EPA 8700-22 Blue; GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS, <br /> To: P.O. Bax 400, Sacramento, CA 95812-0400 <br /> I' <br />