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Jul 11 03 10-33a <br />State of Caiihsr'nic—Enviranmantal Protection Agency <br />Form Approved OMB No. 2050-OD39 (Expires 9.30.99) See Instra AgA a mn ack of <br />Panne or type. Form designed for 8• <br />Frint use on elite f t2• Peweilor, <br />p <br />1. Generator's US EPA IC No. <br />UNIFORM HAZARDOUS <br />ManifestDocumem No, 2, poem' <br />WASTE MANIFEST C A 7 4 0 <br />B 1 3 of 1 <br />Generator'; Name and Mailing Address <br />��'IritLrJ¢.>�/,y d%B�✓`�L�r �X a J'S <br />A. $rohManifestDocume <br />�`ir^1 <br />yi•�'jj� .. B. State Generator's ID <br />j <br />4. Generator's Phone <br />F•r <br />5 ransparter 1 CamArlt any Name <br />P o. US EPA .D Numbar <br />J •� °' I ' I .�t,.�,,, <br />C. Slate TranspoHar'a ID (; <br />EVERGREEN ENVIRONMENTAL SERVICES <br />C! <br />I to ri 1 tJ I p 1 2 4� <br />f <br />r� B. Tranapoater's Phone <br />p 21 S 12 <br />7. Trans 2 Company Name 8. US EPA ID Numbar <br />E. State Transporbr`s ID (F <br />ro U J <br />l / y �� j F, Tranaportors Pho <br />I <br />+ <br />9. Designated aciliy Name and Site Address 10. US EPA ID N,mberG. <br />SAFETY-KLEEN (SAN JOSE} INC. <br />[ <br />State Foeilia 1D <br />I W <br />1021 Beriyesa Road <br />(C (A i Df D I ; <br />Ip <br />San,ase GA 95183 C A DI 0 5 9 4 <br />M. FacsYity's Phone <br />9 4 3 1 0 <br />I�1Q <br />1V US DOT Description rncludin Proper Shi <br />P • I` BShipping Name, Hazard Gass, and ID Number) <br />12, Containers <br />13, Total <br />Z <br />c. <br />No. T a <br />Quontiry <br />e <br />_= <br />IS <br />E <br />b Lr�Blte /�%4�d+atrrg.t3ll4®g2ca s01'' N, c9 . t . <br />aOOo E <br />4 R <br />j u1v ®993 A( 72- <br />C4 <br />A <br />— <br />a <br />av <br />R <br />1 <br />I <br />d. <br />1. Additional Dftcriptions for /Mylerials Listed Above K <br />//, Q fRGvtSa / Cl�nry a. <br />Carl? <br />C. <br />1 S. Sl,eeiof tfandiing tnsPrucPbns and Additional 'mfarmation <br />Codes For Wastes Lis <br />16. <br />p.3 <br />Deportment of Toxic gubuasaa Control <br />Sacramental Cates, <br />Lnlormation in the shaded,,. <br />s net required by Pedsrol aa. <br />EEESS <br />ember <br />20.312 <br />�I <br />800 972-5284 <br />,ed.) <br />1.408-451 <br />14. Unit <br />Ft.Waato Nmber <br />te _ <br />•rami-, <br />5!a <br />EPA/O�er <br />$Pole <br />• <br />24 Hour Emergency R onse TeI, Ida. r- 4 of Lading 0 /�S � <br />/219 r rotective clothin — -- 2y -g � <br />16. GENERAT RTIPKARON: I hereby declare that the contav, of this conal nment are fully andaccurotol • dascrsbsd above <br />marked, an iabelea, and are in all roepeets n prayer condition for iron n hi wo according to a 6Y p1°par shipyfng name and ata clazsifad, pec&ad, <br />apo 6`h y g applicable international and notiono9 government regufaliona. <br />tf 1 am a forgo quintiy ganeroror, I certify that i have o proram in place to reduce the volume and toziaity of waste generated to the degree i hove determined to as econenicdl <br />proa!ica6le and that I hale selected the practicable method at treatment, storage, or disposal currently ovoifable to me which minimi2as the present and future threat to human hockh <br />I'd he environmenh OR, of t am o small quantity generator, I have mode a good faith effort to minimi2e my waste generction and select the best waste management method ihmit <br />avallahle to me and that i con afford. <br />P {{ ped Name�,y <br />a , l e Y1 Y1 Z er tty, !'7 Mrs ✓a l !- - - - naar,rf, oay Te< <br />Name <br />MonthDoY �Yea ? r/ <br />P 19, Oiscropa Indication Space <br />A <br />C <br />I <br />L <br />1 20. Facili .iwner or J scalar Carllflcalion of cal t of hazardous materip!s c ver is aniFast exca t as nc in item 19. <br />� Pr' ad T ed No // Sign ur th <br />as bay Year <br />DO WRITE BELOW THIS LINE. <br />8022A 11/99) White! ?SOF SEND] 'HIS COPY TO CTSC WITH N 30 GAYS. <br />870+0--22 <br />To, F.O ?o� 3G0�, SecramRrta, CA 95812 <br />