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Stole of Coll tornla—tnvuon mental Protection Agency See Instructions OD bOCI( of P49e b. Department of Toxic Substance:Control <br /> Form Approved OMB No.2050-0039(Expires 9-3099) �l Sacramento,Substances <br /> Please print or type. Form designed lar use on elife(12-pit< writer p[ 5§�p <br /> UNIFORM HAZARDOUS ,fir rjWrnia <br /> l•,t UQ"1 ��o �i Ma ifesl Do um 2, Paged) imetroation required <br /> m the shaded areas <br /> J ( J i ` / 's not requited by Federal law. <br /> I WASTE MANIFEST <br /> a x <br /> A. Stale Man'fesr Document Number <br /> °fMalmgAddress R Z AA <br /> +f 1?i)rF CA 95206 B. State Generale,',ID <br /> 7 <br /> o 7 946-5 2.1. <br /> h 4 Gen era tar's Phone ( ) <br /> fV 5 Tra sported Cnmpony Name. - <br /> 6. US EPA ID Nymbar. C. State Transpmrm-'s ID(Reserved.] <br /> w SA I.;`.I'Y—KLEEN SYSTEMS,. INC SCROGOU'751:�t1. D,. Tran,parter,:phne Qt ;? ;r�3-31940 <br /> 0 <br /> O E: State Transporter',ID(Reserved.I <br /> C? 7. Transporter 2 Company Name - 8.:US EPA ID Number <br /> ° 1. Transporters.Phone <br /> "fi Q <br /> U 9. Designated FacilityNameandSiteAddress (}{x,0760 10. IS EPA ID Number G. St°tffs3Fsrtt*,©O084517 <br /> ,J✓3s<_ SAt'ETY (;LEEN SYSTEMS, INC. <br /> SD 2: 6000 X53°'H STREET - CA000-008451'7 H: Fec1ly,Phone <br /> 9a SACRAMENTO CA 95828 Vit& :ta€,-•43i', <br /> Q12. Containers 13. Total 14. Unit <br /> U 11, US DOT.Description(including Proper Shipping Name,Hazard Class,and ID Number) Na Type Quantity Wt/vol Waste Number <br /> ? ° NON RCRA HAZARDOUS WASTE LIkfUI Slate"3D3 <br /> ETHYLENE GLYCOL SOLI,7TYON S LF SS `i'HAN Sf1�S) Dt2 G EPA/Ofher <br /> 3 G CA-332: 343 <br /> N E 6. State - <br /> o N <br /> co E EPA/Other <br /> v R <br /> v A. a stain. <br /> o T <br /> Q EPA/Other <br /> R <br /> rY sate.. <br /> d' <br /> Z <br /> w EPA/Other <br /> U <br /> a' K. Handling Codes for Wastes Listed Above <br /> Zr 1 Addi ionol Di,soription,for Motel els Listed Above <br /> OI.. i' .i ..1 - 14 b. <br /> 0- <br /> Z <br /> N <br /> w <br /> QIs spaalH dl Tl lFaaa dAddit IIf tan '1 ST R/141024 336'f 0002-595 501 <br /> Efi9Ltdr,E91CY REjP 800 40a -':L"760( 24 IR ). IF UNDELTVE:RABLO RETURN TO ,;ENBRATO t, <br /> z s" C:t7L? AT)' HOla-t%ED TO RETAIN , LICIN,1:D SUBSEQUENT CARRIERS AS NECESSARY. <br /> SCOCsY re .7s: 6.51 5: C: L): <br /> 16 GENERATOR'S CERTIFICATION Ih rebydeclare that the contents of this consg entare Full card°ocurotely described above by proper shppmg cameo da e l ,ified,packed, <br /> Q marked,end labeled,and are all respects in proper condition for transport by highway a5ord ng to cable infernal anal and cppl eationall government regular ons. <br /> U <br /> IF I am a large q amity <br /> generator, certify that I have propg en n place to reduce the glume and ra.'ciry f waste generated to the degree have determined m 6e economic 11 <br /> a <br /> practicable and that I o e elected if practicable method f treatment,storage,or disposal currently ovallable to me which minimizes the present and future threat to.human health <br /> ac and the environment;OR,if I am a mall qua}iy generator,I have made a.good faith effort to minimize my waste generation and select the best waste management method)hays <br /> ce ovailalble to me and that I can afford. <br /> OPr ted/Typed Nome Signature Month Day Year <br /> Z <br /> w - T 17 Transporter 1 Acknowledgement of Receipt of Materials ' <br /> RSignature "`) Month Day Year <br /> w R Printed/Typed Name - rw <br /> P - <br /> 0 18 Trans oder 2 Acknowledgement of Receipt of Materials <br /> O 7. Printed/Typed Name - Signature Month Day - Year <br /> W E <br /> Zr R <br /> Ljj 19. Discrepancy Indication Space <br /> Z F J <br /> Cv <br /> 20 For li Omer or O erator CerhPmtion of recai t of hazardous marehals a ed b This m/a sl e e 1 as noted in Item 19' <br /> T SPapled/ Y ed. acre / v , ......ure 'I <br /> 11 <br /> �O NOT'WRITE B OX, `fHl 'LINE: <br /> _t Yellow: TSDF SENDS TfiIS't PY TO GENERATOR WITHIN 30 DAYS. <br /> -(Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />