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State of California—Environmenlol Protection Agency <br /> Form Approved OMB No.2050-00391Expiaes 9-30991 — 855—01 See Instructions on back of a b. Department of Toxic Substance.Coalrol <br /> Pleosd print or type. Form designed for use on elite(12-pikh 1 Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generators US EPA ID No. Manifest Document No. 2. Page I Information in the shaded areas <br /> CAD 983664541 !' 1 is not required by Federal law. <br /> WASTE MANIFEST i V of <br /> 3. Generator's Name and Muilin Address A. State Manifest Document Number <br /> 1905 N MACARTHUR <br /> O TRACY CA 95376-2833 g. State Gemu.toi's ID <br /> nd. Generator's Phone 1209 1 8 3 2-5 200 <br /> N 5. Transporter I Company Name 6. US EPA ID NumberC. State Transporters ID(Reserved.] <br /> U1 <br /> o SAFETY—KLEEN SYSTEMS, INC f C 1 0 0075 50 1 1 1 D. Transporter',Phone 669-5740 <br /> 0 <br /> sD 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Trarmporter's ID]Reserved] <br /> I-1 J SAFETY—KLEEN ( TG ), INC. SCR- 000074591 F. Transporter.Phone <br /> V 9. Designated Facility Name and Site Address 000760 <br /> 10. US EPA ID Number G. SIa1a Foci101y'a ID ® 1 <br /> j <br /> V Z SAFETY—KLEEN SYSTEMS, INC. H. Fe ulysphane <br /> N o 6000 86TH STREET CAO 000084517 <br /> f1LL SACRAMENTO CA 95828 916 386-491s <br /> 12. Container 13. Total Id. Unit <br /> V11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Ty". Quantity Wt/Vol I.Waste Number <br /> R a. NON RCRA HAZARDOUS WASTE LIQUID 5me 3!3> <br /> 3 G ETHYLENE GLYCOL SOLUTION ( LESS THAN 50%) DM G EPA/cl qe <br /> N E CA-342, 3436. state <br /> o N <br /> MW E EPA/Other <br /> v R <br /> C.v A State <br /> o T <br /> T G .EPA/OIAer <br /> R <br /> w d. State <br /> r <br /> w EPA/Otbet <br /> V <br /> w <br /> J. Additional Descriptions for Materials listed Above K. Handling Codas for Wastes ,red Above <br /> `w EA) 342 a. 14 b. <br /> O <br /> w — <br /> � d. <br /> Q <br /> Q 15. Special Handling Instructions and Additional Information <br /> MFST R//T#099663997 0000-3715-52 <br /> zEMERGENCY RESP 800-468-1760( 24 HR ) . IF UNDELIVERABLE RETURN TO GENERATOR. <br /> SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br /> W <br /> H <br /> r 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipring name and are classified,pocked, <br /> amarked,and labeled,and are in all respects in proper condition for transportby highway according Id applicoble international and notionaPgovernment regulations. <br /> J <br /> IF I am a large quantity generator,I certify that I have a program in place to reduce dee volume and toxicity of waste generated to the degree I have determined to be economically <br /> N practicable and thatI have selected the praclicable.methad 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 I 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 /> ac available to me and that I can afford. <br /> QPrinted/Ty�Nameryry ;. 7 Signature <br /> Z `y/ ' I j in <br /> w T 17. Transporter 1 Acknowled amen)of Receipt of Materials <br /> w ' Printed/Type Signature 1 o r <br /> X <br /> w S - .. <br /> P <br /> w 0 18. Trans ortar 2 Acknowled amen of Recei t of Materials � - <br /> O TR Printed/Typed Name Signature Monts Day Year <br /> QN <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> L <br /> 20. Facili Owner or O erotor Certification of receipt of hazardous materials covered by this manifest escept as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />