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Please print or type. (Form designed for use on elite (12 -pit ewriter.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDbUS 1. Generator ID Number 2:`Page Tof - 3. Emergency Response Pho 17or 14. Manifest Tracking=Number: <br />WASTE MANIFEST CAD71325IT 6 <br />1-800-468-1760 __ 1 100272109 CEX <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />CAL TRANS DIVISION 10 CAL. TRANSIST I <br />I643 S. ST 1603 S S ST <br />STOCKTON CA 75206 EQUIP DrVISION <br />Generators Phone: 2 5 ) STOC TON CA 75205 <br />6. Trans orter 1 Compan Name U.S. EPA ID Number <br />S FpE T Y— LE SYSTEMS, INC. T R 0050950 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />1: <br />8 Designated Facility Name and Site Address_ ' «° ' <br />'�� IA.EEN SYSTEMS, 114C.U.S. EPA ID Number <br />6000 SSTJ STREET <br />SACRAMENTO CA SES <br />— 5 — <br />Faality's Phone: CA 000OB 517 <br />ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. UnitHM and Packing Group (if any)) No. Type Quantity Wt.NoL 13. Waste Codes <br />'HAZARDOUS WASTE# LIQUID: N.G.S. �bDS ' � S� <br />Qo A L 2 PG III (0037) <br />W <br />,Z1, 2fie.4—RCRA HAZARDOUSSTE LII € G <br />134 <br />r€ OUEOUS IMMERSION CLEANER) <br />3$0I—MCRA HAZARDOUS WASTE, LIQUID G-134 <br />(Ate O S PARTS WASHER SOLUTION) <br />4. <br />14. Special Handling instructions and Additional InformationSK 962709 00003 o 0172 0742 2 <br />i <br />SK. AUTHORIZ—E-DTO RETAIN LICENSED SUBSEQUENT C. R ERS AS,XECESSARY <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name; and are classified, packaged-, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according_to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EIRAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a Iarge,duantity gen atef or} or (b if I am a smgli�,tfuantity generator) is true. <br />Generator's/011e rs Pi ted/Typed Name Signatu fi Month Day Ye <br />A VV <br />—r 16. International Shipments f <br />�. �a <br />i ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br />Z' Transporter signature exports only): <br />Date leaving U.S.: <br />17 Transport <br />w, noedgment of Receipt of Materials,; <br />, <br />Transport r 1 Printed ed -Name S'g�nature Month Day Yea <br />a f <br />Q Transporter'2 Printed ed Name""" <br />Signature ". Month - Day, Year, , <br />F <br />18. Discrepancy <br />" 18a: Discrepancyndication Space <br />❑ Quantity, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Altemate Facility (or Generator) <br />JU.S. EPA ID Number <br />' _._ <br />V' <br />W Facilitys Phone: <br />Lu 1Be. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z; <br />W19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® 1, 2' <br />1 3• 4. <br />K1 41 <br />s <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered bjthe manifest except as noted in Item IBe <br />PnntedlTyped Name Signatures,,Month Day Year <br />If 4.r <br />EPA 8700-22 (Rev. 3-05 Previous editions are obsolete, <br />) 5 ) 1 II S# I I ? DESIGNATED FACILITY TO GENERATOR <br />