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Please print or type.(Farm designed for use on elite(92-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Gen �"DNurnber <br /> Form Approved,OMB No.2050-003 <br /> 9 mergency Response Ph�i! 4Manifest cracking NumberWASTE MANIFES <br /> 5..Generator's Name and Mailing Address <br /> Generator`s Site Address(if different than mailing address} <br /> iL"if fit} <br /> TRIC" CA 95376 91F <br /> Gererator'sPhone: •$36-19+71 <br /> 6.Transporter 1om <br /> Cpany Name <br /> SYSTEMS, I U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S EPA ID Number <br /> S.Designated Facility Name and Site Address <br /> ::IAFETY--KL.EEN SYSTEMS, IW �)011 t U.S.EPA ID number <br /> 4000 88TH STREET <br /> 5'16-388-4913 St�CRAM�''ll CA._95821? <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10Containers <br /> HM and Packing Group(if any)) . 11.Total 12,Unil <br /> 1. No. Type Quantity WI.NoI, 13.Waste Codes <br /> hAZ! <br /> o <br /> (AQUEOUS PAR Lt1�N'�F.'R SOLUTION) <br /> Q <br /> L <br /> Z 2. <br /> uL1 <br /> t.7 <br /> 3 <br /> 4, <br /> 14.Special Handling instructions and Additional Information I( 1Q1��Q1777 00:0 _ Q <br /> i N E1 SURSi= T CARST ki' <br /> 15. GENERATORVOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described atiave by the prayer shipping name,and are classified,packaged, <br /> condition for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> marked and labeled/placarded.and are in all respects in proper <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 21(if i am a large quantity generator)or(b)(rfI am a small quantitygenerator)is true. <br /> Generator's aror's Printed/Typed Nar.ue Signature , <br /> ' r � Month Day Year <br /> r 16.International Shipments -12 1 <br /> 4 1 ❑Import to U.S. Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> LO' 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 Printed/Typed Name Signature <br /> 0. Month Day Year <br /> to <br /> Transporter 2 PdntedlTypod Name Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space y� <br /> Quantity Type L I Residue 0 Partial Rejection <br /> 1 0 Full Rejec#ion <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> ,r U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w <br /> ^1 1. 2. 3. <br /> 14- <br /> 20. <br /> Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature <br /> "/. <br /> Mon <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. Month Day YeaDESIGNATED FACILITY TO GENERATOR <br />