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} Stake of Cali Tornio—Environmental Protection Agency , <br /> Form Approved OMB No_2050-0039(Expires 9-30-99) Set: Instructions on back r 'age 6. Department of Toxic Substances Control <br /> Please print or tyae. Form i`o,,igned for use on.1ite(12-pik .writer. Sacramento,California <br /> r UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded..as <br /> F WASTE MANIFESTU J of is not required by Federal law <br /> CAD 9 8111917161212181 . 1 <br /> 3. Germralor's Nam.and Moiling Address A. State M mikot.Document Number <br /> BIG vAYiY FORD 1 22420830 <br /> SM Auto <br /> Cardw W"* B. State Gen.star's 1D <br /> h A. Genararor's Phoma 1 1 "CA 0e4 <br /> 621d'SflIIS Ub <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID(Reserved.] <br /> mROMIC Environmental Technologies <br /> O D. Transporter's Phone <br /> O <br /> cG CD- 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID Reserve . <br /> f.MQ E Transporter's Phone <br /> Facility Na a aAede9. Designatedy 10. US EPA ID Number G. State Facility's ID <br /> (D_d OMIC Environmental TechnologiesIC IA JID 10 P 19 14 15 12 16 15 17 <br /> NZ 81 ®,ay Road H. Facility's Phone <br /> N L Palo A ct CA 5 7 1324-1638 <br /> 1'N6 11. US DOT Descri do roper Shipping Name,Hazard Class,and ID Number) 12. Co^toiners 13. Total 14. Unit <br /> No. Type Quantity WI/Vol I. Waste Number <br /> r Za. �I Staty t= e <br /> Other regulated substances, liquid N.O.S.B L> EPA/Other <br /> 3: c NA 3082 PGHi RQ Contains Eth ene Gl of Q b T NONIS <br /> oN b. Sate <br /> E EPA/Other <br /> v R <br /> v A <br /> 6 T state <br /> mR EPA/Other <br /> � R <br /> t d. star. <br /> f Z <br /> .` W <br /> F V EPA/Other <br /> w <br /> to J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> k o waste Ethylene Glycol 01 b. <br /> N <br /> 4 <br /> (Antifreeze), d. <br /> a <br /> Z 15. Special Handling Instructions and Additional Information <br /> O <br /> ' z Gloves and Protective Clothing Emergency Response Phone 8001765-4248 <br /> W ROM IC Profile #2011111 _ Emergency Response Guide Book #171 <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents.(this consignment are fully and accurately described above by proper shipring name and are classified,packed, <br /> Umarked,and labeled,and are in all respects in proper condition for transport by high y cording to applicable international and nationaPgovernment regulations. <br /> J If I oar a large quanliy generator,I certify that I have a program in place to re ce the vo a and toxicity of waste generated to the degree I have determined to be economically <br /> d practicable and that I have selected the practicable method <br /> Tam <br /> srora r dispos urrently available ro ma 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 faith e he imize my waste generation and select the best waste management method that is <br /> Table to m and that I can afford. <br /> O <br /> y Prin / SignaG a Montdh� Day Ywy z X' d U <br /> >? r <br /> W T 17. Transporter I Ac nowI c1 emenl of Receipt of Materials _ <br /> K E Prin /Typed�Na/qa SignatuM. nl _ Doy� Year <br /> W R 18. Trans porter 2 Acknowledgement of Receipt of Materials / <br /> O i Printed/Typed Name Signaturq Month Day Year <br /> f W E <br /> j Q R <br /> 1 U 19. Discrepancy Indication Space <br /> I Z F <br /> _ q <br /> C <br /> I <br /> L <br /> 1 1 20. Facilihr Owner or Ocesrotor Certification of receipt of hazardous materials covered b this m "Pett except as noted in Item 19. <br /> t T Printed/Typed Nome i Signature r Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (1/99) (Generators who submit hazardous waste For transport out-oF-state, <br /> �. EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />