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State of California—Environmental Protection Agency <br />Farm Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of pages 6. Department of Toxic Substances Control <br />Please print or type. Fo,m designed for use on elite f 12 -pit=h) fypew iter Sacramento. California <br />OJ <br />LCiQ <br />�V <br />Q�Q <br />Mce <br />wO <br />U- <br />R4 -Q <br />CVu <br />_Z <br />3 <br />US <br />US <br />Z <br />V <br />w <br />N <br />Z <br />O <br />V) <br />w <br />of <br />J <br />Q <br />Z <br />0 <br />Q <br />Z <br />LU <br />Q <br />V <br />J <br />rV) <br />0 <br />V <br />Z <br />W <br />LLJ <br />0 <br />�s w <br />N <br />Q <br />V <br />`1A <br />DTSC 8022A 11/1 <br />EPA 8700-22 <br />1 Generator's US EPA ID No Manifest Document No <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />Is not required by Federal law, <br />WASTE MANIFEST <br />I A 9 6$8 81 1 1 1 q53 <br />4 I I <br />a` 1 <br />3. Generator's Name and Mailing Address MIRACLE MILE DRY CLEANERS <br />A. Stale Moniftio Document Number <br />82 W CASTLE ST <br />24639150 <br />STOCKTON CA 95204 <br />S. Slate Generator 'sID <br />A . Generator's Phare ; 2 0 9) 4 6 4— 0 4 11 <br />1 � j <br />5. Transporter 1 Company Name 6 US EPA ID Number <br />C, State Transporter's ID (Reserved. <br />SAFETY—KLEEN SYSTEMS . INC. TXR000 509 3 <br />D. Transporter's Phone 800 669-5740 <br />7. Transporter 2 Company Nome 8 US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />V Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />000760 <br />C Q 010 4 17 <br />SAFETY-KLEEN SYSTEMS, INC <br />H. Facility's Phone <br />6000 88TH STREET CA0000084517 <br />SACRAMENTO CA 95828 <br />916 386-4913 <br />11. US DOT Description (including Pro Skipping Name, Hazard Class, and ID Number <br />p 1i g per ppi g I <br />I2. <br />Containers <br />13. Total <br />Quantity <br />Id. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />T e <br />a <br />Slate <br />WASTE TOXIC LIQUID, ORGANIC N. 0. S. <br />741 <br />(TETRACHLOROETHYLENE)6.1II <br />OR#/GH( <br />DF <br />P <br />EPA/Other <br />G <br />OEFO02H( ERG#153) (DO081DO39IDO40) <br />S- <br />F002 <br />E <br />I State <br />RI <br />Tc <br />State <br />0 <br />EPA/Other <br />R <br />d <br />Stara <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />I (A) D007 D039 (A) D040 <br />14 <br />c <br />d. <br />15.5 ecial Handlir Instructions and Additional Information <br />EM RGENIC RESP#800-468-1760 24HR <br />5 <br />SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIER, AS NECESSARY. <br />A 12627 <br />B C D <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 are classified, packed, <br />marked, and labeled, and are in all respects it proper condition for transport by highway according to applicable <br />international and national government regulations. <br />If I am a large quantity generator, ! certify that I have a program in place to reduce the volume and toxicity of <br />waste generated to the degree I have determined to be economically <br />future human health <br />P,acticable and that I have selected the practicable method of treatment, storage, or disposal currently available <br />and the environment; OR, if I am o small quantity generator, I have m a good faith effort to minimize my <br />available to me and that 1 can offoro. <br />to me which minimizes the present and threat to <br />waste generation and select the best waste management method that is <br />Pri ed/T. ped Name not re <br />1777 <br />Morth Day Year <br />c5i i I ol Y1 0 1,6 <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Printe ed Name <br />5 r we <br />Month Day Year <br />s <br />G / 01c/1016 <br />P <br />0 <br />18. Trans otter 2 Acknowledgement of Receipt of Materials <br />T <br />Printed/Typed Name <br />S <br />Month Jay Year <br />IR <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />I <br />20 Facility Owner or Operator Certification of cei t of hazardous materials covered by this manifest except as noted <br />in Item 19. <br />TPrinted/T <br />T <br />ame <br />Signature <br />Month Day Year <br />DTSC 8022A 11/1 <br />EPA 8700-22 <br />