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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30.99) <br />Pledse print or type. Form designed for use on elite (12 -pitch) typewriter. <br />O <br />W1 <br />WI) <br />n <br />N <br />LO <br />W <br />,�r• O <br />\iI CR <br />U15 a <br />U <br />Z. <br />�O <br />eB LL <br />•ire `g Q <br />VU <br />Z <br />t, <br />3 <br />N <br />O <br />W <br />GO <br />N <br />Q <br />O <br />CD0 <br />r <br />at <br />w <br />h <br />Z <br />W <br />U <br />LU <br />V) <br />Z <br />O <br />N <br />W <br />_ Q <br />Z <br />0 <br />a <br />Z <br />w <br />t_ <br />U <br />J <br />d <br />tY <br />O <br />11/29/2005 <br />See Instructions on back of page 6. <br />DJ1132607 <br />Department of Toxic Substances Control <br />Sacramento, California <br />DO NOIl Wifff BELOW THIS LINE. <br />DTSC 8022A (1/991 White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 To: P.O. Box 3000, Sacramento, CA 95812 <br />UNIFORM HAZARDOUS <br />Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />�*LA 2 a ' <br />of 1 <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address - <br />Sears #1288 SAME <br />A. State Manifest Document Number 25157256 <br />110 Pacific Avenue <br />B. State Generator's ID <br />Stockton. CA 95207 <br />4. Generator's Phone (( _ <br />,:I C I Al, L ® 0. , 0-101 0131317121 <br />5. Transporter 1 Com pony Name 6. US EPA ID Number <br />C. State Transporter's ID (Reserved.) <br />Clears Harbors Ernr Services -Inc M I AlD: 0131913 2 2 12 15 10 <br />D. Transporter', Phone 781)'849-1$00 <br />7. Transporter 2 Company Name - 8. USiTPA ID Number - <br />E. State Transporter', ID [Reserved.] <br />F. Transporter', Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />Clears Harbors Ban Jose.LLC <br />e A 05 g ;, - d 3 •A ;`0 <br />1021 Berryessa Road <br />H. Facility's Phone <br />San Jose, CA, 95133 1 C I AlDI 0151 914191413 1 10 <br />40$ 451_5000 <br />US DOT Description (including Proper Shipping Name, Hazard Class, and 10 Number( <br />12. Containers <br />14.11. Unit <br />W. Vol <br />- I. Waste Number <br />No. <br />F enfi <br />a NON RCRA HAZARDOUSVASTE LI®UID(ETHYLENE GLYCOL) <br />f13.Total <br />SfQ1e <br />G <br />L <br />Nb• <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />C. <br />State <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />1. Additional Descriptions for. Materials listed Above <br />I.a.(Lj.:, <br />K. Handling Codes for Wastes Listed Above <br />b. <br />C. <br />d. <br />15. Special Handling, Instructions and Additional Information EMERGENCY PHONE # (800) 483-3718 <br />t <br />Wear Proper PPE when handling waste 11 a: 040544.343 2X %0 = , . <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition far transport by highway according to applicable international and notional government regulations. <br />If I am a large quantity generator, I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicolly <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Prin�Wyped Name <br />, lure <br />Day/ <br />y <br />/M�onth�J ,pYear <br />R17. <br />Trans rter 1 Acknowledgement of Receipt of Materials <br />A <br />Prin -dA/TTyppeedd Nammee,�rJ�f Si ature <br />Month Day �Yjear <br />01,51 V16 I <br />D <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />B <br />L <br />( <br />20. FacilityOwner or Operator Certification of receipt of hazardous material covered b this manifest except as noted in Item 19. <br />T <br />v <br />Printed/Ty ed Name• <br />0, 0"M � <br />S n r <br />".,:) <br />o Da Year <br />cS" <br />P .- <br />a <br />DO NOIl Wifff BELOW THIS LINE. <br />DTSC 8022A (1/991 White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 8700-22 To: P.O. Box 3000, Sacramento, CA 95812 <br />