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Mate at C.alitornia—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039[Expires 9-30-991 See Instructions on back <br /> Plea sc}prfnf or type. Form designed far use on elite 11 2-pirc write:. �' Department of Toxic Substances Control <br /> Sacramento,C°lifornia <br /> UNIFOt`?vl H,AZAR©Old$ 1. Generator's US EPA ID No. Manifest arum nl <br /> 2. Page 1 Information in the shaded areas <br /> „. �� �,., <br /> WASTE MANIFEST is not required by Federal law. <br /> U 9 8 Y. a 7 Z C, 7 J of <br /> 3. Generolor's Name and Mailing Address <br /> A. State MaPtiFesf Document Number <br /> Int+�r�t:e�tra le�t�irn;Ktieln�tl 23576139- 0 5�y 6 �,.,, <br /> 62lf Ha�vy Drive I 13 <br /> Sttlisl ktOn, CA 05206 B. State Generator's ID <br /> 4. Generator's Phone ( 209 lIfI44- it k <br /> cN 5. Transporter 1 Company Name E, US EPA ID Number <br /> arcs ROPAIC �'B'IVIr )nffir,litiElC c&C ECsI 14�lIE' C. Slate Trpnsporfer's 1D[R served.) <br /> 0 <br /> O r. �.� D. Transporter'5 Phone <br /> C? 10649 14 115 12 16 <br /> 7. Transporter 2 Company Name 6501324-1838 <br /> 8. US EPA lD Number E. State Transparter's ID[Reserved.) <br /> Q F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address <br /> g ROMIC C En�rironmeent Tochnalogin:;<r 10. US EPA ID Number G. Store Facility's ID <br /> ZW 081 Bidl Road lr A 9 <br /> X� O H. Facility's Phone <br /> ly) J - t Palo�61aa, C, 3 A D � �F 9 +� "� 2 � 5 i► 6501324-1638 <br /> V 11. US DOT Description[including Proper Shipping Name,Hazard Class,and ID Num6erl 12- Containers 13. Total 14. Unit <br /> Z o. No. T e Quantify WI/Vol I. Waste Number <br /> Other ragitilated 'Silisllfst8f3 nes, 11011d WO- -ii State <br /> 343 <br /> G NA 3082, P,13111, RG, Contains Ethylene Glycol � EPA/Other <br /> N h. �. TITNONE <br /> oo E Slate <br /> R <br /> v A <br /> EPA/Other <br /> oT <br /> 000 0 State <br /> R <br /> uj <br /> EPA/Other <br /> rks d, - <br /> t- <br /> Z State <br /> ua <br /> U <br /> f u EPA/Other <br /> t) J. Additional Descriptions for Maler-Ws tistad Above <br /> O Waste lEtliviene Gly-col K. Handling Codes for Wastes Listed Above <br /> cL <br /> a.(Antifreeze) �1�6 b. <br /> Q c. d. <br /> O 15. Special Handling Instructions and Addilional Information --- <br /> w Oliil IC Profile ii 1'G 11 E aaergericy RespoasLa all,", <br /> de: BoeaiC #1�' <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the coolants of this consignment are fully and accurasel described above by proper ship ing name and are classified,packed, <br /> U marked,and labeled,and are in elf respects in proper condition For transport b highway according fa applicable <br /> p <br /> Y P Y fl y g pplicable international and national government regulations. <br /> J t .. <br /> If I am a large quantify generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical)yy <br /> v) pracficahfe and That I have selected[lie practicable method of treatment,storage,or disposal currently available to me which minimizes the present pod future threat to human heallh <br /> and the e.virnnmenF;OR, if 1 am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O available to me and that f can afford. <br /> VPre"nted/Typed Nc a Signature <br /> Z /"fit/ Monlly Day �yyear <br /> ssu l fit? f v? t , ` - e r— .y'�pao�Gr `°—vr•� [/wry r C <br /> (� <br /> RT i 7, Trans arter 1 Acknaw ed ement of Receipt of Materials <br /> w X m <br /> PrintedJTyp Nae Sig at { <br /> LU 5 r <br /> LU P /4 Mont Day Ye <br /> tei to <br /> w B 1$, Trans crier 2 cknow ed emenl of Receipt of Materials <br /> O T Prinled/Typed Nome Si lura <br /> LU E <br /> u) R Month Day Year <br /> 4 <br /> V F 19- Discrepancy Indication Space <br /> Z <br /> A <br /> C <br /> I <br /> 2D. Facile). Owner or O eratar Certification of tacit r of hazardous materials covered b this manifest axca t as noted in Ifegl 19. s <br /> T Printed/Fyped Name <br /> y Signature <br /> Month Day Year + <br /> DO NOT WRITE BELOW THIS LINE. ` <br /> i <br /> DISC 0 (1/99) <br /> EPA$7700--22 Blue: GENERATOR SENDS THIS COPY TO DISC WITHIN 30 DAYS. I <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />