Laserfiche WebLink
State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30.99) See Instructions on back of Qe 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 112-pilc ri _ Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document 2. Page I Information in the shaded areas <br /> WASTE MANIFEST C D 8366 54 j DNl of 1 is not required by Federal law. <br /> 3. Generator's Name and Mailing Address DEPUY ORTHOTECH O GGGJJJ A.`stole, Ifee Document Number r� r�r�l� <br /> 1905 N MACARTHUR 20522070 <br /> $ TRACY CA 95376-2833 B. State Generator's ID <br /> A. Generator's Phone 12091 832-5200 <br /> N S. Transporter I Company Name 6, US EPA ID Number C. Sxsa Transporwr's ID[Re rved.l <br /> N <br /> o SAFETY—KLEEN SYSTEMS, INC R O O S 0 D. Tmnsporter's Phone <br /> 0 <br /> c? 7. Transporter 2 Company Name 8. US EPA ID Number E. Store Tmnsporter's ID[Resa_rve1669-5740 <br /> ps SAFETY—KLEEN ( TG), INC. C M101,791, <br /> 00 4 91 F. Tranapb er'a Phan. <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Fadlly's 10 <br /> �¢ 050144 D <br /> IN SAFETY—KLEEN ( SAN JOSE ), I H.f«;ry,Pnone991 <br /> NO 1021 ®ERRYESSA RDD 0 94 4 30 <br /> SAN JOSE CA 95133 Al I 1 00 S45-3358 <br /> 12. Containers 13. Total 14. Unit <br /> NJ 1. US DOT Description(including Proper Shipping Nanta,Hazard Class,and ID Number) No. Type Quantity Wt/Vol 1. Waste Number <br /> TOSIC LI4QUIDS ORGANIC N. O. S. store211 <br /> 3 G TETRAFLUOROETHANL" POLYOLS D ' ' G EPA/Oth., <br /> o N 6. Slate <br /> co E EPA/Ofher <br /> v R <br /> v A c State <br /> o T <br /> EPA/Other <br /> R <br /> ac <br /> w d. stale <br /> t— <br /> VEPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above K, Handling fadbr i Weskit,listed Alam. <br /> O a. 14 b. <br /> N <br /> c. d. <br /> Z <br /> Z15. Special Handling Instructions and Additional Information <br /> O MFST R/T#099663994 0000-3715-52 <br /> EMERGENCY RESP 800-468-1760( 24 HR ). IF UNDELIVERABLE RETURN TO GENERATOR. <br /> Z SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br /> LIU <br /> 16. GENERATOR'S CERTIFICATION: Thereby declare that the contents of this consignment are hilly and accuralelY described above by proper ship ing name and era classified,pocked, <br /> Vmarked,and labeled,and are in all respects in proper condition For Transport by highway according to applicable inlernalional and.ouch ai. vernmenl ragulotions. <br /> If I am a large q onliy generator, certify That have a program in place to reduce the volume and toxicity of waste generated so the degreehaw determined to be economicallyy <br /> i practicable and that I ave selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heollh <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 /> available to me and that I can afford. <br /> ' Si n <br /> Printed/Tynature <br /> ante !� �� 9 <br /> Z f <br /> oil I 'i .F; <br /> ped <br /> w T 17. Transporter I Aclinowledoemment of Receipt of Materials <br /> W A Printed/Typed No ``, ( Signature ^�(O° °r <br /> W A \/'SC € _ lel <br /> O A 18. Transporter 2 A`ckne lysed . em of Recei t of Materials Signature <br /> "'zzr sss' <br /> TPrinled/Typed Nome Signature Month Day Year <br /> y <br /> 'R <br /> J 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> 1 20. Facili Owner or Operator Certification of recei 1 of hazardous materials covered by this manifest except as noted is Item 19. <br /> T Printed/Typed Name Signature MonthDay Year <br /> r <br /> ,Q gy j}) DO NOT WRITE BELOW THIS LINE. . <br /> Dt� �2drnAf 000227 3812 <br /> Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />