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71 k <br />Please print or Wipe. (Form designed for use on elite (12 -pitch) ' .) <br />Form Approved. OMB No 205M39 <br />EPA Form 8700, Rev. Previousgitiog re sol GENERATOR'S INITIAL COPY <br />um I iFoRrA Hmwoua, <br />1 1. Generator ID Number <br />12. Page I of <br />3. ni�Rea ponse Phone <br />m I4"­1760WASTEIFEST <br />racking Nurnber <br />.0 7.10555 FLE <br />W MAN <br />rG`an� 14a;;'Mailing Address Generatces 8709 Address (if diftnant than mailing address) <br />Pq4EU.A''TfWKTW INC <br />SM E FftFMGNT ST It " OR DAVIS <br />STOCKTON CA 9510r_ <br />Generator's Phone: 2" 3 94. --,500'0 <br />6.ragtl 1 Pany'NOMS U.S. EPA ID Number <br />F TEMS, I NV,. <br />UEN F'A'S TXRZ0WQl')30 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and SftsAddress.TY4 <br />c 4EM -KLEEN SYSTEMS INCUD Number <br />, <br />1722 f-TWEIR CREEK WO -h) <br />Ty' �GL <br />ilea <br />940--4S3-'15P@@ TXIBA776 <br />Facilit es Phone: I <br />ga. <br />9b. U.S. DOT Description (including Proper Shliong Nam, Hazard Class, ID Number, <br />10. Containers <br />11.7btal <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (d any)) <br />Quantity <br />Wtftl. <br />cc <br />1.WN RCRA HAZARDOUS WASTE SOLID <br />D11 <br />P <br />512 QU15 <br />(EMPTY vRFS1DUE LAST rVINT-AINEDil ETHYLENE <br />GLYC(X SOLUTIUN9 AtffIFREEZE) <br />W <br />2. <br />149W4W4A 514M M rt:-, <br />3. <br />4. <br />14. Special Handling instructions and Additional Information <br />SK SHIP#EU*X242 U 187 P-729307 CSG.- <br />24KR EWRWNCY (34138) <br />SK ALITHID TO MME GORSEOLIENT <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby dedane that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeleftlacarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulations. ffe)w shipment and I am the Primary <br />Eiporter, I =* that the contents of this consgriment conform to the term of the attached EPAAdmowledgment of Consent <br />I certify that the waste minimization statement Identified! in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (d lama small"'nitily gerieralor) is true, <br />Hera sFrInIsqTypW NaM sqnature,NWM my,ar <br />_j <br />I- <br />16. International Shipments <br />[.:] import to U.S. ❑ EX 41t from U.S. Fort of entry/exit <br />2C <br />Transporter siIinature for exports 2&: Data leaving U.S.: <br />CC <br />LU <br />17 TransporlarAdamwiWilmientofReceipt materials <br />Transporter I ft*.Vryped Name Day Year <br />co <br />Transporter 2 Printedfryped Name re month Day Year <br />W <br />F- <br />18. Dscrapancy <br />18a. Discrepancy Indication Spam El Quantity 1:1 Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Gen ) U.S. EPA 10 Number <br />Q <br />LL <br />Facil Phone: <br />18c. Sigrtature ofAltarnate Facility (or Generator) Mo&, Day Year <br />19. Hazardous Waste Report Manapmerd Method Codes (i.e., codes, for hazardous waste ftwwathkment, dieposa1, <br />end recycling systems) <br />1: on <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in ftern 18a <br />Printed!Typed Name SignatureDay Yesr <br />EPA Form 8700, Rev. Previousgitiog re sol GENERATOR'S INITIAL COPY <br />