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State-of California—Environmental Protection Age cy 7--1 ZC; P.:o-2— Form'Approved OMP (Expires 9- 0.99) - See Instructions on back of page 6. Department of Toxic Substances Control Please print or type. Form designed for use on eh a(12-pitch)typewriter. Sacramento,California UNIFORM HAZARDOU 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas A'r0 X00 C2.t�'f.4 is"�1 e.:r rl� �1 is not required by Federal law. WASTE MANIFEST of 3. Generator's Name and Mailing Add ass t.I A;.,.1 1` 1 C, v J'.- State Document Number I.-t- A. SMf PO DOX 5095 ROO 3EOO�.N 23473025 O !•j-Al"I f`: yd'�f.ii�l t�s� s;j �J M1J.-.tlr � B. State Generator's ID - LO 4. Generator's Phone( 209) 4' 4-401. H[� 'f~ :s6jpC) 9 ff tV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] w) op :iter F'w'f•Y- KLEEN ,s".ly TEIIS, INC 'MR, 0s.J 5090 r D. Transporter':Phone o f3 ,f 6,69-57,40 N 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserved.] Q F. TrdnspoiferVP hone. ._. -. ©U 9.,Dpi f Fa iffy a nd5•te r •Lr+4'a• 10. US EPA ID Number G. State Facili 's ID Z 15 0-50 SALIDA BLV O ;:,AL I DA CA ` 5368 CAT000613962 H. Facility's Phone vc-z209 545-1011 Q 12. Containers 13. Total 14. Unit V 1 1. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Number[ No. Type Quantify Wt/Vol I. Waste Number K a. USED-t1 State aw USE C:L..E•r�taIN ` C.0M.P0UI D"C'3, 114, U. T- P. N. Ell G 1.34 1.-z0UI D (NOT USD T' OR USEPA, RL-OULArEU) � � EPA/Other 3 G tktWEOf.S PART-rl W SHER 9CLU1"I N (e. *r:i iL i o N b. State oo - - - oD V R'=`'- 51 EPA/Other CN A o T ` State m O R EPA/Other cle tw- d. State - Z Lu V EPA/Other w h J. Additional Descriptions for Materials Lis ed Above K. Handling Codes for Wastes Listed Above Z O 14 b. a _ w 1_$ S e ia�Ha dlin nstructions and Add ional Information t•r'' A� 3•Q �:J'' �"l' S,}i,}:_'�y+�t�.{-} ! 1.ft fs2C�E IL RESP ## , 16--977—:7777 '24HR I Q Z . Lu 16..GENERATOR'S CERTIFICATION: (her by declare that the contents of this consignment are fully and accurafefy described above by proper shipping name and are classified,packed, Umarked,and labeled,and are in all re pects in proper condition for transport by highway according to applicable international and national government regulafions. j If I am a large quantiy generator,I c rtify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically JI rL practicable and that I have selected th racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environment;OR,iF I am a sm II quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is Oavailable to me and that I can afford. i•�1 } Pr /Typ ame Signature Month Day Year i a w T 17. Trans orter 1 Acknowledgement of Rec i t of Materials O R wA Prince yped Name Signature Month Day Year w 0 18. Transporter 2 Acknowledgement of Rec i t of Materials ..� T Printed/Typed Name _ ---.___ _.._._..._.. ._._ _ Signature _ _. ..- -... .- _. __._ _ ...Month _....Day_ -Year_. . w E Q R V 19. Discrepancy Indication Space Z F A C i I L 20. aci ity Owner or Operator Certification of race i t of hazardous materials covers f b his manifest except as noted in Ite 1 f T rime./Typed Name Signatu e ,— nth Day Year Y I l i DOOT RI E`BELOW THIS LINE. v Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. 4 DTSC 8022A(1/99) � � (Generators who submit hazardous waste for transport outstate; EPA 8700-22 JY j�+li` produce completed copy of this copy and send to DTSC withiithin 30 days.)