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ole of California—Environmentol Protection Agency <br />,;ivaard OMB No. 2050-0039 (Expires 9-3099) <br />rint type. Foran designed for use on elite (12-pikh) typ <br />See Instructions on back of pr 6. Department of Toxic Substances Control <br />Sacramento, California <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />I/99 (Generators who submit hozordous waste for transport out-of-state, <br />DTSC 8022A <br />(1/991 produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 870D-22 <br />�i ORM <br />1. ('°neraloh US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />N FI HAZARDOUS <br />WASTE MANIFEST <br />..n ' f .� <br />i' not required by Federal law. <br />C �D000043565 Lr K / <br />a f <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />s�^'99 P' a y^; <br />mi' /' <br />-:.:u-rosy+ Hissam ! MIa <br />i; L'.. G v v <br />16 IS "Is P.`E8t!5s St <br />R. Slate Gen iramrs ID - <br />4. Generator's Phone I Ewvaa I �r A �haiti Qs <br />III I 1013 18 10 10 1 I 'ft A <br />@l;sIH <br />N S S <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Res_rved.l <br />ROMIC Env3ronMeri Tecnnol<agses <br />D. Transporter', Phone <br />7 <br />IC IA 10 10 10 19 14 15 16 1517 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transpartpr's ID [Reserved.] <br />F. Transporter', Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />ROMIC E:nvlrannient Technologies <br />ICIAIOIOI0191415121615171 <br />H. Facility's Phone <br />2081 Lay Dead <br />East Malo Aito CA .9+4303 IC JA 10 10 10 19 14 13? IS 1-017 <br />6501324-1636 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Numbed <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />WI/Vol <br />I. Waste Number <br />No. <br />Type <br />a <br />Stale <br />Other regulated substances, liquid N.O.S..9 <br />Lifti <br />EPA/Other' <br />E <br />NA 3082, PGIII, RQ, Contains Ethylene Glycol <br />T <br />111101i <br />b <br />Stale <br />N <br />E <br />_ <br />EPA/Olhm <br />R <br />A <br />state <br />T <br />C. <br />0 <br />EPA/Other <br />R <br />d. <br />stale <br />EPA/Other <br />J. Additional Descriptions for Materials Listed AboveK. <br />Handling Codes for Wastes <br />Listed Above <br />Waste Ethylene, Glycol _. <br />a. 01 <br />b. <br />(pntiirell <br />J. <br />15. Special Handling Instructions and Additional Information <br />Gloves and Protective Clothing Emergency Response Phone SOIIJ-166-4242 <br />ROMIC Profile #201111 Emergency Response Guide Book 4171 <br />16. GENERATOR'S CERTIFICATION: )hereby declare that the contents of this consignmeat are fully and accurately dauribed above by proper shipping name and are classified,packed, <br />labeled, in in condition for transport y highway according to applicable international and national government regulations. <br />marked, and and are all respects proper <br />If I am a large quantity generator, I cerlify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economic a11 <br />and that have selected the practicable method of treatment, storage, or disposal curraetly _available to me nimizes the present and future threat to human health <br />practicable <br />and the environment; OR, if I am a small quantity generator, I have made a goad Faith effort to nian my w generation an elect the best waste management method that is <br />�`� <br />IF <br />1 available to ..and that I can afford. H J <br />d/Typad Name nalurd' Month Day Year <br />yv3 <br />t T <br />� <br />17. Trans orei 1 Acknowled emanl of Receiof Materials <br />i <br />'gra <br />Monih Day Year <br />p� <br />i R <br />Prin Typdd Name s <br />lur f <br />5 <br />I 1 G,. <br />i P <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />i 7 <br />Printed/Typed Name Signature Month Day Year <br />> E <br />R <br />j19. <br />Discrepancy Indication Space <br />F <br />c A <br />C <br />I <br />L <br />20. facility Owner or O erato4.Ceslificalion of recai 1 of hazardom materials <br />covered b this manifest axce las noted in Item 79. <br />1 <br />T <br />Prinled/Typed Noma] <br />Signature ManBs Day Year <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />I/99 (Generators who submit hozordous waste for transport out-of-state, <br />DTSC 8022A <br />(1/991 produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 870D-22 <br />