Laserfiche WebLink
Slate bF Coli Porn d -Environmental Protech on Agency <br />Form Approved OMB Na.. 2050-0039 (Expires 9-30-99) Is See Instructions on back of9 Pe a 6. <br />Please print or i pe. Form designed for use on elite (12-pikh) hDewru,r Department of Toxic Substa G fml <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SE14DS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />]',�(tL A 1/ 00099e: 24. 7 i 5 ) t!1'J(i'066286 (Generators who wbmit hnmrdous waste for Transport out-oFslate, <br />700-2 ��) � <d r:c B) 000 2 4 0 R 4 67 produce completed copy of this copy and send to DTSC within AO d...., t <br />' i I <br />UflUEARM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document <br />Sacramento, California <br />No 2. Page 1 Information in the shaded oreos <br />WASTE MANIFEST J. <br />al required by Federal law. <br />3. Generator's Name and Mailing Address - <br />of <br />A. State Manifest Document Number <br />;,ENTRAL VALLEY WAST'L'' VC: <br />(� <br />?.9 s '* <br />p <br />i E: 7F:iJL''F, R!� <br />220y5979® <br />°' 67 F <br />j <br />F > B',?li 241001 . <br />�T <br />B. Stale Generator's ID <br />s <br />dl. colingtaloh Phone CA 95241 <br />s <br />1 <br />t <br />5. Transporter 1 Componq Name '' -' • i 6. Us EPA ID Number <br />C State Tmnsporler's ID [Reserved.] <br />>�rETY-.x>r_E.v sr�T�r1 T'RJ c. Sr, -•:,c, <br />INC. <br />Transporter's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. stale Transporter's to [Res&154a) 6 6 9 4 0 <br />L-. - ;ti ! t �!" tI - ? <br />F. Transporter's Phoneu p(✓ _: P yt (_?_K,� Es <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />000658 <br />SAF'ETl-KLEEN SYSTEMS, INC. <br />t A. <br />H. Facility's P one <br />9'100 LAGRANGE ROAD K 'D 1 9,49 0 <br />6 <br />`Name, <br />1�ilo <br />1 US DOT =Description Proper Shipping Hazard Class, and ID Number) <br />12. Containers <br />13. Totol <br />� Td. ni 1 <br />J - .r, <br />a. <br />No. <br />Type <br />Quantity <br />Wt/yol <br />I. Waste Number <br />State <br />R 'vdASTE PETROLEUM DISTILLATES, N, 0. S. <br />E <br />D'IESEL FUEL, GP.SOLINE) <br />�)� <br />L),.] <br />!) ) ? <br />EPA/othm ' <br />N4e.- <br />.x_ C ,t.. 12 <br />F <br />R <br />T WASTE SOLIDS CONTAINING FLAMMABLE <br />�- <br />State <br />A <br />L )U1 D, N. G. S. ( GASOLINE, BENZENE) 4. t <br />� <br />ry % <br />r)� <br />`, r� t <br />c <br />EPA/011ie - <br />T <br />{e_ ., � v_„ <br />O <br />R' <br />state <br />EPA/Other <br />d. <br />state <br />EPA/Other <br />1. Additional Descriptions for Materials Listed Above <br />K. Handling Codes For Wastes Listed Above <br />IAt DOOB 1018 IB) DO1& <br />6 <br />a_T)�'( %)"? <br />r <br />d. <br />15. Special Handling Instructions and Additional Information <br />EMERGENCY RESP 800-468-1760(24 HR). IMF FUNDELI(VERABLEIRETURHZTOIGENEPATOR. <br />SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the conte"ytl'.pF,K9T.FAignAehfare Pa)I)%Q1c21ra dn,rib"Bove 4$,prZar shipping name and aD 9lossified,packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway <br />according to opp)icable international and nationol government regulations. <br />If I am a large quantity generator, I certify that ) have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economica11 <br />Practicable and than hove selected the racticable method o treatment, storage, or disposal currently available to me which minimizes the presentand future threat to human health <br />and the environment; OR, if I am a small quantity generator, I have made a faith to <br />good effort minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Typed Name <br />Signatslre �^• <br />(.f�)ontlr� ay Yea <br />A' <br />17. Tra s orter 1 Agkno4led ement of Recei t of. Mpteria s <br />A <br />N- <br />Priated/Typed I)ome <br />_ <br />�j <br />R <br />18. Trans orter 2 Acknowled ement of Receipt of Materials V <br />T <br />L <br />Printed/Type me <br />-7c) I� 1'/. rr?� ... <br />Signature ' <br />.�—. <br />Yonip� Day Year. i <br />.- ``'i <br />/�v� _- J-' <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />1 <br />n <br />20. Facili Owner ar O Iti(ii mh n of racer. t of hazardous materials covered b thorn, mfrs) dxce 1 as noted in Item 19. <br />T <br />Y <br />7tat <br />Printed/Typed Name <br />��-{it .,_ <br />Si mre <br />'t if ii �s 'u ... <br />,Ye <br />I <br />y <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SE14DS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />]',�(tL A 1/ 00099e: 24. 7 i 5 ) t!1'J(i'066286 (Generators who wbmit hnmrdous waste for Transport out-oFslate, <br />700-2 ��) � <d r:c B) 000 2 4 0 R 4 67 produce completed copy of this copy and send to DTSC within AO d...., t <br />