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Please print or type. (Form designed for use on elite (12 -pit writer.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST CPD 01 T <br />1 I -S0 -4608-176 <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />CAL TRANS DIVISION 1 CAS."Keays '-D ST 10 <br />1603 T 1603'S B T <br />Y CK If 9 EQUIPDIVISION <br />Generator's Phone: STOCKTON CA 95245 <br />6 t°° o e 4 p Om Y T M . INC, U.S.EPAID—Number <br />7. Transporter 2 Company Name U S ERA.ID-Number <br />8. Designated Facility Name and Site Address SAFETY— LEEN SYSTEMS, INC. 000760 U.S. EPA ID Number <br />00V 86-TH STET <br />SAC A NTO CA 75825 <br />Facility's Phone: <br />Cts <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (If any)) No. Type Quantity Wt.Nol: 13. Waste Codes <br />1HA Z ARRC tS WASI E, �LITQ1-1 D,, N. C. S. D039) 0039 1 <br />0 7 NA -3062 PC 111 <br />34 <br />9 c <br />Z. 21qG1-RCRAHAZARDOUS ASTER L DPS C <br />2-5 <br />3s4K"IRCRA HAZAPMUS UASM, LIQUID Dai 134 <br />IS PARTS UASNERSOLUTION) <br />4. <br />14. Special Handling Instructions and Additional Information C s g 0040326'?10 000037. 172 0?"50 24 <br />24 HR EMERS NCY # 844°-46 17 (S TY--MFER `" T-4138.) <br />) <br />SK A TWOD TO RETAIN L10EM ED SUBSE0LIERT lERS AS NECESSARY <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. EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) ("rf I am a large quantity generator) or (b) (if I am a small quantity generators true. <br />Gene ato aG®ffei�ors Printed/Fyped Name Signator - Month Day k Year <br />—j 16. International Shipments" Z.,. <br />F- 0 import to U.S. ❑Export from U.S, Port ofentry/exft:' <br />z- Transporter signature, for efforts only): Date leaving U.S.: <br />LLI <br />17. TransportePcknowledgment oflBeceipt ofMatedals �- q <br />E TransF er1 Pnntedrryped Namj <br />a P �d ' ` SiTature I Month Da Yea <br />W <br />Q Transporter 2 Printed/Tf ped Name Signature <br />Month Day Year <br />t- <br />- _. 18. -Discrepancy - .: <br />18a. Discrepancy Indication' Space <br />0 Quantity ❑ Type Manifest <br />❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />_J.. _ <br />CV <br />Facility's Phone: <br />W 18c. Signature of Alternate Facility (or Generator) Month Day ` Year <br />Q, <br />H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and.recycling systems) <br />W3. H141 <br />1: <br />±Pr,inted/Typed <br />esignated Facility Oxm or Operator. Certification of receiptaf hazardous materials covered by the manifest except as noted in Item 18a <br />Nam r Signature + Month Day Year <br />07 <br />EPA oS4..w 2 (f ev. 3-05� Previous editions— are obsolete. DESIGNATED FACILITY TO .GENERATOR <br />