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Statg„ Caljjornia—Environmental Protection Agency .. <br />S@@ IltStl UCt10ns OA bdCRC :�. Department Toxic Substances'Control <br />Form pproved MB No. 2050-0039 (Expires 9-30-94) g@ of <br />Please <br />pe. Form designed for use on elite (12 -pitch) typewriter. Sacramento, California <br />ZARDOUSCAn <br />UNIFORM�,;NIFEST <br />1. Generator's US EPA ID No. Manifest Document No. <br />,3, <br />2. Pageo1 <br />q i in the shaded areas <br />isfnot reormat'u <br />fired by Federal law. <br />WASTE <br />77 9679 <br />3. Generator's Nome%andMailing Address PACIFIC COAST <br />DU <br />O <br />X335 S STOCKTON .. T <br />to <br />PO BOX 880: <br />LODI CA 95240 <br />to <br />4. Generator's Phone Q09 934-3352 <br />00 <br />p <br />5. Transporter 1 Company Name - - 6. US EPA ID Number <br />O <br />00 <br />SAFETY-K.LEEN CORP. Z 9 <br />2 <br />-1, <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />U <br />10 <br />a <br />10 <br />(Z <br />9. Designated Facility Name and Site Address 10. US P N er <br />AF ETY-°ALEEN CORP. <br />0 <br />5050 SALIDA BLVD. <br />�,. <br />SAL I A ; ;' CA 95:168 CA)0T"000613948 <br />a <br />U <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number), <br />12. Containers <br />13: Total • <br />Type Quantity <br />14. Unit` <br />WT/Vol <br />No. <br />~ <br />RG WASTE COMBUSTIBLE L I QU I t). N. 0. S. �� <br />DM <br />`G <br />( PETROLEUM N PMTHA) NA 1993 PGI I ( 0001) i' <br />oE <br />(ERG#27) 6.7 LBS/GAL <br />00 <br />N <br />E <br />b <br />R C P NDS, CLE -. <br />t: <br />C14 <br />R <br />." <br />d <br />A <br />� <br />O <br />;.,00 <br />.- <br />j <br />® <br />c <br />_. <br />R <br />~ ' <br />d. <br />'[ Z <br />LU <br />W <br />H <br />Z <br />0 <br />CL <br />' w <br />. <br />yQ <br />0 <br />a- <br />15. Special Handling Instructions and Additional Information <br />EMERGENCY RESP#708--88 - b HR <br />f <br />Z! <br />:LUSOti <br />A. 0 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br />J <br />Q <br />packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable federal, state and international laws. <br />U <br />If I am a large quantity generator, I certify that I have a program in place td"°r�duce the volume and toxicity of waste generated to the degree I have determined to be <br />-' <br />economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future - <br />t1 <br />threat to human health and the environment; OR, if 1 am a small quantity generator, I have made a good faith effort to minimize my waste gene7ation and select the best <br />` <br />waste management method that is available to me and that 1 can afford.ce <br />(� <br />Pn ed/Typed Name <br />natureont <br />- ` <br />Djsy ('j r <br />// <br />Y ; ,,� <br />U _ <br />t <br />raps orter 1 Acknowledgement of Receipt of Materials <br />LU <br />R <br />N <br />Printed/Typed Name <br />I <br />Signature / <br />" /_,aY - r <br />ar <br />W <br />s <br />1 d <br />r-0 <br />o18. <br />Trans orter 2 Ac nowled ement 'ol <br />lfezeit of Matenals <br />LU <br />T <br />Printed/Typed Name _ <br />.. <br />Signature '� _ . <br />Month Day Year <br />LL. <br />0 <br />E <br />R <br />U.11 <br />19. Discrepancy Indication Space <br />N <br />U <br />A <br />Z <br />— <br />C <br />I <br />L <br />I20. <br />Facili Owner or Operator Certification of receipt of hazardous materials <br />cove -red by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (7/92) <br />EPA 8700-22 Yellow: GENERATOR RETAINS <br />