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Stole of Colifornio—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expire,9-3099) 185-01 See Instructions on backge 6. Department of Toxic Substances Control <br /> Please print or type. Form designed For use on elite(12-pitcewriter. 90 Sacrament,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page I Information in the shaded areas <br /> UNIFORM HAZARDOUS CAD 983664541 j is not required by Federal law. <br /> WASTE MANIFEST t-f of <br /> 1.C.aner¢teis.dwne,gadJdaJi,w.4ddrass A. Stale Man.. Document Number,r)S65 997 <br /> RACY tlKs.tlli Ll7URf CA 95376-2833 B. SbM Generator's ID vi iV� ( 4YF MV ` <br /> LO A. Generator's Phone�09 1832-5200 <br /> n <br /> cV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID fReurved.1 <br /> AFETY-KLEEN SYSTEMS, INC SCR 000075150 D. Tronsportor's Phone <br /> S 800 669-5740 <br /> m ler Na PA E. State Trans R sone <br /> �il� f-�C�' 1 �4PG)e INC. orIer',ID <br /> §6 d°��1/4591 P Is—�I <br /> /�/�seQ F. Transporter',Phone 916 366-4913 <br /> V/V 9. Designated Facility Name and Site Address 050.144 10. US EPA ID Number G. Stale iM'S1 49 3 Q <br /> d Q AFETY-KEEN SAN JOSE ) , I <br /> �� 021 eEA YES`$ RD CAD 059494310 H. Faclity',6one <br /> COo 9AN JOSE CA 95133 600 545-3358 <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No.—o Containers 73. Total 14. Unit <br /> VeV NType Quantity Wt/Vol I. Waste Number <br /> TOXIC LIQOROEUIDS ORGANIC, N. O. S. 5t°t° 211 <br /> - (( TETRA THANE,THANE, POLYOL ) DM EPA/O+. <br /> 3 G UN2810 PG II ( ERG#153 ) NONC <br /> o N b' State <br /> m E <br /> R EPA/Olher <br /> V A c State <br /> T <br /> 0 EPA/Otho, <br /> R <br /> w d. Such, <br /> UZ <br /> EPA/Other <br /> w <br /> 1. Additional Descriptions for Materials Listed Above K. Handling Cedes For Wash Listed Above <br /> O <br /> d <br /> W <br /> Y <br /> C. d. <br /> Q <br /> om6t0 ti_0n#I66Zaja76O( 24 HH ) . IF UNDrLIOtAABLE RETURN TO GENERATOR. <br /> a K CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br /> Z <br /> w SKDOT# A: 80592 B: C1 D: <br /> x <br /> r <br /> .0 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignmentom fully and accurately described above by proper shipping name and are classified,pocked, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according Isapplicable international and national government regulations. <br /> V w.. <br /> If I am a large quantify generator,I certify that I have o program in place to reduce the volume and toxicity o{waste generated to the degree I have determined Io be economical[ <br /> N. . practicable and that I have selected the Firocticable method o treatment,storage,or disposal currently mailable b me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a,mall quantity generator,I have made a good faith effort to minimize my wash generation and select the best waste management method that is <br /> d' available to me and that I can afford. <br /> O. PrinhwJ(/� ame Signature onl a r <br /> Z4'Ai.r✓�.— <br /> w T 17. Transporter 1 Acknowled ement of acei t of Materials <br /> �j ! Printed/Typed Nan,�q_.. Signature +s �.1on /Day., Year <br /> W <br /> w p 18. Trans porter 2 Acknowled ement of Racei t of Materials <br /> O T Printed/Typed Name Signature Month Day Your <br /> W E <br /> N R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Focili Owner or Operator Certification of recei 1 of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> P$QL# A))0002052685 <br /> SM L# A)0002273812 <br /> Yellow: GENERATOR RETAINS <br />