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$tate"of California—Environmental Protection Agency+ <br />Form Approved OMB No. 2050-0039 (Expires 9-30-94) S@@ Instructions OA bQ61C Qg@ 6. Department of Toxic Substances Control <br />Please' pri <br />e. Form designed for use on elite (12-pitch) typewriter. Sacramento, California <br />UNIFORM HAZARDOUS . <br />. <br />1. Generators US EPA ID No. Manifest Document No. <br />CAD OA49et <br />2. Page 1 <br />2 <br />Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />of <br />3. Generator's Name and Mailing Address <br />O <br />835 S STOCKTOP4.ST <br />to <br />PO BOX 8843 <br />L.OD I CA 75240 <br />C14 <br />4. Generator's Phone ROT) 334"3352 <br />O <br />6 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />O <br />00 <br />SAFE i'Y--KLEEN CORP. ILI3 984908202 <br />U <br />7. Transporter 2 Company Name 8. US EPA ID: Number <br />.. <br />` <br />p ggqqc� �Q <br />9 e t d li Address - 107y§ <br />Z <br />0 <br />S i i ?I Yt» 'i <br />5050 SAL, I DA BLVD. <br />SAL I DA CA 95368 CAT 000613968 <br />U <br />Z <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 />EE <br />a RG WASTE COMBUSTIBLE LIQUID, N. O. S. <br />DM <br />3 <br />(PETROLEUM PHTHA) NA 1993 P# I I I (DO0 2 ) <br />Ci <br />G <br />E <br />( ERC# 27)4. L. 7 LBS/GAL <br />o <br />E <br />b• Rte WAtTE CDMPOUNDS, CLEANING LIQUID <br />M <br />V <br />(MONOETHANOLAMINE) 8 N 1760 Q I I I -v <br />DM <br />A <br />(DOOS t E X 60 ) <br />000 <br />T <br />p <br />C. <br />rr <br />R <br />W <br />Z <br />d. <br />W . <br />U <br />in <br />Z <br />- 0 <br />O: <br />N <br />W <br />J <br />Q <br />Z <br />O <br />gg,,c� jQ� npj -.. '. ,:. ,: :. ;.:, "- ,:.'...• a s:E s: t: .. <br />Ecl�lV4 i �nwrr.fff�} <br />W <br />SKDOT# A. 585 B. 866 C. <br />J <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 />packed, marked, and labeled, and are is all respects in proper condition for transport by highway according to applicable federal, state and international laws. <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 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 />tL <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 generation and select the best <br />N <br />waste management method that is available to me and that I can afford. <br />0 <br />ame <br />rinted/Typed f <br />Suture <br />Month Day or' <br />U <br />T <br />, �. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name(` ( <br />(X <br />Signature . <br />Month Day ear ' <br />W <br />S <br />U <br />Y <br />g <br />o <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />tL <br />i <br />Printed/Typed Name' <br />Signature <br />Month Day Year <br />LL <br />0 <br />E <br />R <br />w <br />19. Discrepancy Indication Space <br />N <br />Z <br />C <br />6 <br />I <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials <br />_. <br />covered 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 />