Laserfiche WebLink
Staffs of California—Environmenfol Protection Agency <br /> Form Apll!rovea OMB No.2050-0039(Expires 9-30-99) See Instructions On back Or ige 6. Department of Toxic Substances Control <br /> Please print or type. Form designed hr use on elik(I2-pikl miler. Socmmento,California <br /> 1. GenerabYs US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS -5911 <br /> 1 is not required by Federal law. <br /> ";.WASTE MANIFEST C. A p 9 81119171612121 8 "11 <br /> s' . iaf 1 <br /> 3. Generouses Name and Mailing Address A. State Manifest Document Number tr}} /[ �y <br /> BIG VALLEY FCMD L <br /> SM Auto CoMw Cinge 4 +� <br /> 74 <br /> O CA $W tai B. State Generator's ID <br /> 4. Generator's Phone( ley 966. <br /> IN 5. Trans rier 1 Company Name 6. US EPA ID Number C. Stare Transporter's ID)Reserved] <br /> W <br /> TiDC <br /> Environmental TechiTal les <br /> D.Tronsporler's Phone <br /> xlO <br /> 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter',Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Faciliys ID <br /> IP- a ROMIC Environmental Technologies IC JA ID 10 (19 14 15 12 IS 15 17 <br /> �� 2081 Flay Road H. Facility's Phone <br /> I4ic;r0 <br /> East Palo Alto, CA 54303 PAPPPD19 PS 0 12 6 15 V 6501324-1638 <br /> eNa 12. Containers 17. Total 14. unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type 13, Tota Wt Vol I. Waste Number <br /> s <br /> Z a. State <br /> Other regulated substances, liquid N.U.S.3 343 <br /> 3 c NA 3062,7, P0ili1, R(3, 4 OntaiTES Ethylene C31yC01 0 10 11 TIT Ii <br /> EPA/Ob., <br /> E NONE, <br /> o N 6. Stare <br /> m E <br /> rR EPA/Other <br /> i v A C. State <br /> o T <br /> ao O <br /> R EPA/Other <br /> 1 <br /> 1 ac <br /> W <br /> J. $late <br /> Z <br /> Z <br /> i w EPA/Other <br /> V <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codex for Wastes Listed Above <br /> o Waste Ethylene Glycol- 01 b. <br /> W <br /> (An"freexe) <br /> � C. d. <br /> I Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> a Glover, and Protectivir. riathing Emergency Response Phone 80017664248 <br /> Z ROMIC Profile 8201111 Emergency Response Guide Book #171 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consi9 ja <br /> aadaccurably describeda6ove by proper shipping name and are classified,packed, <br /> Umarked,and labeled,and are in all respects in proper condition for transport bym!n wording ro applicable international and nations government regulations. <br /> If I vm a large quantity generator,I certify that 1 have a program in place to r uce tme and toxicity of wastegenerated ro the degree I have determined to 6e economicallN practicable and that I have selected the practicable method o treatment story dcurrently available to me which minimizes the present and future threat tohuman healand the environment OR,if I am a small quantity generator,I have made a god itt minimize my waste generation and select the best waste management method that is <br /> available to an.and that I can afford. <br /> y P inbd Signatu —' Month Day Years <br /> Z ' �-- 1G 2 C� <br /> k Z <br /> 4 w T V.Trans her 1 <br /> Ac kno ed ement of Receipt of Materials <br /> V R r <br /> w A Prin /T;ypyed Name Si tare} r /Mon Day Year <br /> t w i // ' fly / h '✓^^ �/ U <br /> f ss_ R 18. Trans rte,2 Ac6mwled ement of Recei t of Momrials I <br /> ( O RT Printed/Typed Name 9nalu Monti Day Year <br /> w <br /> H E <br /> R <br /> U19. Discrepancy Indication Space <br /> I Z F <br /> k- - A <br /> C <br /> 1 <br /> L In <br /> I 20. Facility Owner or Goitrous,Certification of receipt of hazardous materials covered 6 this at z a t as notal in I 9. <br /> T Printed/Typed Name �� Signature Monts Day Year <br /> T &.416 y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 22A(l/99) (Generators who submit hazardous waste for transport out-of-state, <br /> DISC 80 <br /> EPA 87022A produce completed copy of this copy and send to DTSC within 30 days.) <br />