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State of Culifomia�—Envlonmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-96) See Instructions an baCll page 6. Department of Toxic Substances Contra <br /> Pleose prim or tyr - Form designed for use on euro(12prjlrslfpewriM. Sacramento,California <br /> IIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded area <br /> Is not required by Federal law. <br /> WASTE MANIFEST C A D 9 8 1 9 7 6 2 28 1af 1 <br /> O 3. Generator's Name and Moilino AddrossFQRD A. ate Manifest Document Number <br /> n 8262 Auie Center Cirele <br /> N <br /> n <br /> N CA 70M in B. State Generator's ID <br /> cram 1 <br /> 5. Trans r 1 Compan Name 6. US EPA ID Number C. State Transporter's ID <br /> IT IC [nvlro mental T chnologies <br /> CAG 0 0 9 4 5 2 6 5 7 D. Transporter's Phone 6501324-1638 <br /> J <br /> Q 7. r 2 mpany No 8. US EPA ID Number E. State Transporters ID <br /> QI I I I I I I I I I 1F. Transporter's Phone <br /> Z 9. Demanded Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> N o HOMIC Environmental Technologies CAG 0 0 9 4 5 2 6 5 7 <br /> 2087 Bay Road H. Facility's Phone <br /> ti East Paw Alta, CA 94303 ICIAIDIOIO19141512161317 6901324-1638 <br /> M 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. T Quantity Wt/Vol I. Waste Number <br /> in x <br /> o. ^ State 341 a3s <br /> 3 Other regulated substances, liquid N.0.5.9 I`//�f('} <br /> oNONE <br /> E NA X1082, PGill, RQ, Contains Ethylene Glycol 0 0 1 T EPA/ thcr <br /> ggo N b. State <br /> t a E <br /> V R EPA/Other <br /> A <br /> cp T C. state <br /> ^ O <br /> W R EPA/Other <br /> r <br /> w d Stam <br /> U <br /> w EPA/Other <br /> 0 Z <br /> J. Additional Descriptions for Materials Listed Above Kr Handling Codes for Wastes Listed Above <br /> N Waste Ethylene Glycal a. Is. <br /> 'Antifreeze) <br /> Q d. <br /> 0 15. Special Handling Instructions and Additional Information <br /> P <br /> Gloves and Protective Clothing Emergency Response Phone 8001766-4248 <br /> W ROM IC Profile 0201111 Emergency Response Guide Book 0171 <br /> x <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and ore classified, <br /> Q packed,marked,and labeled,and are in all respo 1s in proper condition for transport by highway according to applicable international and national government regulations. <br /> U <br /> If I am a large quantity generator, I certify than I have a program in place to reduc me volume and toxicity of waste generated to the degree I have determined to be <br /> Neconomically practicable and Mat I have selected the practicable method of comment, 1 rage,or disposal currently available to me which minimizes the present and future <br /> threat to human health and the environment;OR, if I am a small quantity ahr, 1 ode a good faith effort to minimize my wash generation and seleo the best <br /> 0 wash management method that is available to me and that I can afford <br /> Printed typed Na a Sig Month Day /�Year <br /> Z 1 17 anipwarr I AckholfwWdoement of Receipt of Material V <br /> W R <br /> (� A Prt /Typed Nam - Si re Month Day Year <br /> W S <br /> wP <br /> O 1 rhr 2 Aduawled ement of Receipt of Material <br /> sty T Printed/Typed NameSiyneture " Month Day Year <br /> O e � <br /> y 19. Discrepancy Indication Space <br /> Q F <br /> U A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or rotor Cerfification of receipt of hazardous materials covered by thi ifeetexw as d in Rem 19. <br /> T Printed/Typed NoSignature Month Day Year <br /> r <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-state, <br /> j DTSC BW2A (9/94) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 87022 <br />