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print or Form for we on eNte Q-Otchl tYP ,�_ Form OMB No.X39 <br /> a_ � $ 1.Gerreretor IU Number s g 2.Pepe 1 of 3.Emergency Ple so Response Phone 1 �� <br /> i1-800-468-1.? <br /> 4ftwalmls Name asci r 363 Address Generator's Site Address(if different then macing address) <br /> T" '#.iE rHLAHO <br /> 4A W IVALPICO RD <br /> TRACY CA "a-76 9197 <br /> S 1wlC� $YSTi� IS. INC. U.S.EPAIa 3 <br /> 7.TmnWmW 2 Company Name U.S.EPA ID Number <br /> 8.Designehad Facility Name and Sfie Address Std' T Y—Kf,.EEN S YST�i"�.�r INC. 000760 U.S.EPA ID Number <br /> 6000 RSTH STREET <br /> SACK ENTO CA 9 <br /> ►3 —fib-49 = <br /> F Phone: CAOOOOO8451 i <br /> .9& 9b,U 3.DOT Das70M(including Proper Shipping Name,hazard(lass,ID Number, 10.CaMainers 11.Total 12.Unit <br /> HM and Paddry Gfo4(dm!')) No. Type Quendty yyILA(d 13.Waste Codes <br /> )iON—RCRA HAZAROWS U14STE, LIQUID on ,,$� a NONE 134 <br /> (ftA€EGOS WtS WASHER St TION <br /> M <br /> 3. <br /> � 4. <br /> 44.Special Hang Inafr„c'om and AddfBonel i"b"tlon <br /> ;�� TPC>~(�1f�S:3s�? � Otl:.���'T�"':'•�� 00���0$0� (r��$ <br /> fig $JJjMR12EQ <br /> TO RETAIN LICENSED SURSEOMUT CARRIERS RECESS"Y <br /> 15, 11pR%K FFEROR'8 CERTIFICATION:I hereby declarethat the contents of awfully and accurately desabed above by the proper shipping name,and ora clusifind:packaged, <br /> niAllml stint labeladoacarded,and are in all respells M proper owdlion for transport swording to appkabie international and nationai govremmental regulations.if eVort shipment and I am the Pdmmy <br /> Exporter 1 oertlfy that the contents of tips consignment conform to the temp of the attadiad EPAAdmaiv%dgment of Consent. <br /> I a6tAfy that to waste mkrimizalion ststamient Identified in 40 CFR M 27(a)(If I am a large quantity generator)or(b)(111 am a small quarilk generator)is true. <br /> GeneratorsiEllfero�stiirilpoliyped Name Signature Month Day Year <br /> J 1e <br /> ❑Import to U.S. ❑Export hom U.S. Port el entrylexit: <br /> Transporter signature(for w9orts only): We leaving U.S.: <br /> 17.Traisporlet{tdutarAadgnterit of Recalpt of rrlateriels <br /> T—MI"I.O.ar 1 F teulffyped Now Signature { Month Day Year <br /> aw <br /> rerrportar yped Nffine $' Momh <br /> . Day 'Year <br /> 18.Disaeparwy <br /> 188.Discrepancy hocadon Space ❑ cuantiy ❑Type ❑Residue ❑Partial R*cBon ❑Full Re)edion <br /> Manifest Reference Number: <br /> 14b.Allemste Faa'figr(or Generator) U.S.EPA ID Number <br /> F cwA Phare: <br /> Ilk Vqnotum ofAkmate Fadrdy(or Generator) MonthDay Year <br /> 19.Har wdous Vft to Report Management Method codes(i.e.,codes for Hazardous waw treatmern,disposal,and reading systema) <br /> 1: 2. 3. 4. <br /> 20.Designated Fadily Owner or Operator:Certification of receipt of hazardous materials covered byte manbst exoapt as noted in Item 18a <br /> Name re Monoth Day Year <br /> raw I 1 1 <br /> EPA Form 87OD-22Rev.3-05) Previous editions are obsolete. <br /> �s3 f GENERATOR'S INMAL COPY <br />