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State of Cali fornia—Enviran,rlental Protection Agen y _.�• `,,�'—•f,-),t i`
<br /> Form,Apprpve O n=9050-0039(Expires9-3 -99) ,See Instructions on back Of page 6. Department of Toxic Substances Control
<br /> n Please print cr type. Form designed for use on elit (12-pitch)typewriter. Sacramento,California
<br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> UNIFORM HAZARDOU ; f;'i'�?'c3C0?b$r C X01 i q r
<br /> WASTE MANIFEST 1
<br /> not
<br /> re uired b Federal law.
<br /> of
<br /> 3. Generator's Name
<br /> ,and Mailing Add ss ht, 1•,,
<br /> � ; B�,( .:_. A. State Manifest Document Number
<br /> PO BOX a(395 rn�o 1i� w,Ec;0 N 23473026
<br /> O C31 A • RA
<br /> MON c A 945t3-0995 B. State Generator's ID
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<br /> LO A. Generator's Phone( 20? :CI•7''1-401 S; HF :) CIT
<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] I
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<br /> cp GAf'ET L'—KLEEN SYS t EMS, INC F n.R'101.1'-3i"5.09 ( D. Transporters.Phone
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<br /> aD 7. Transporter 2 Company Haq e - 8. US EPA ID Number - E. State Transporter's ID[Reserved.]
<br /> F. Transporter's Phone -
<br /> V ____ _ G State Fac(it's ID -.
<br /> --CV) --Q;'pe i p esd.Fatili erg andSite-A� ress'-�•,� .0 --� 10:US ID�Namber- �- --- -
<br /> Q .�`� "c_g SYsr M „ �Ivc:, rra C??tQ -
<br /> ' rJ( (JG�S't3TI-I STREET i 7 ", H. Facility's Phone _
<br /> y'ACRAM,:..1' TO CtA 95828 C�`•..�U�JG084S1
<br /> 1 916 386--4913
<br /> 3
<br /> < 11. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Number) 12, Containers 13. Total 14. Unit r
<br /> I�U No. Type Quantity Wt/Vol I. Waste Number
<br /> = a. State
<br /> HAZARDOUS WA TE': L.I QU I D, N. 0. S. r.'r G 134
<br /> NIA3082 PG I I i (l;039 H ERS*171 r ' EPA/Other
<br /> 3 G r�Q'JI"(OUS BRAKE S LUT ION(G. 3##/GA!_; - S I�039
<br /> O N b. State
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<br /> R EPA/Other
<br /> V0, c, State
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<br /> aao O
<br /> R EPA/Other
<br /> Lu d. State
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<br /> w EPA/Other-
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<br /> _ criphons.for,Mater�ials Lis ed Above „ ,, _ K. Handling Codes for Wastes Listed Above -
<br /> 1 Additional Des _ __. •,,..-._ ,.
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<br /> Z t r t:, L 722 :,. 25E 4(,177 'wC)C 0:3 703V4 _'Tf
<br /> 5 ci I'❑ lost nd tin Iln r a'on�•
<br /> r�f� ' �t�? ? � ' f — ' -f 777 24HR
<br /> Q SK AUTHOR1Z'ED TO RETAIN LICENSED SIJUSEGUENT CARRIER, AS NECESSARY,
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<br /> LLI A S'3'~ Y C
<br /> t- SITE: � 0G E S MI[ E Rei STOCK N,'
<br /> 16. GENERATOR's CERTIFICATION: I her by declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified,packed,
<br /> peas in proper condition for transport by highway according to applicable international and national government regulations.
<br /> V marked,and labeled,and are in all r
<br /> If I am a large quantiy generator,I c rtify that 1 have,o proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically
<br /> a practicable and that I have selected th practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health
<br /> `n and the environment;OR,if I am a s all quantity generator,I have made a good Faith effort to minimize my waste generation and select the best waste management method that is
<br /> ac available to me and that I can afford. /J
<br /> OPrinted/Typ Name Signature..� l Month Day Year
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<br /> �w T 17. Transporter 1 Acknowled ement of Rec i t of Materials
<br /> R Month Da Year
<br /> w p Printed/ ed Name Signatre /.�
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<br /> .._:_ .LU S _
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<br /> w0 18. Transporter 2 Acknowled ement of Rec iipt of Materials
<br /> 0 RPrinted/Typed Name Signature Month Day Year
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<br /> V 19. Discrepancy Indication Space
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<br /> 20. Facility Owner or Operator CertiFicatio4 of receipt of hazardous materi covered by thii,momf4t e.cea 6 no ed in Ite 19.
<br /> Z; `nted/Typed N mq a �1 f Signature on Da -yyea
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<br /> DO NOT W ITE L IN
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<br /> Yellq�L IS COPY TO GENERATOR WITHIN 30 DAYS.
<br /> DTSC$0224'(1/991 MeM r submit hazardous waste for transport out-of-state,
<br /> A-8700-22 jj..�� omp eted copy of this copy and send to DTSC within 30 days.)
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