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C?e of Cakf Agency . ----_ . <br />+0. OMB No. 2050-0039 (Expires 9.30.96) See Instructions on back of page 6. Department of Toxic Substances Contr, <br />pnnt or type. Form designed for use on ante (11 -pitch) typewriter. <br />W <br />OZ <br />9. Designated Facility Name and Site Address 10. US EPA ID Number d <br />Romic Chemical Com. <br />2081 BaNy Road - <br />East Palo Alto, CA 94303 ICIAIDIOIO19141512161517 <br />11. US DOT Description (including Proper Shipping Name; Hazard Class, and ID Number) 12. Containers <br />No. TYP <br />a. <br />R.Q. Waste Gasloine Mixture, 3, UN 1203 <br />PG II ERG #27 (E)001 D018) T' r <br />b. <br />C. <br />rm <br />15. Special Handling Instructions and Additional Information <br />ERG 31 <br />24 Hr. Contact F ` S e iC�`Ndl dCN 1'1i' <br />24 Hr. Contact <br />Sacramento, California <br />2. Page 1 I Information in the shaded areas <br />is not required by federal law. <br />1 of 1 <br />13. Total 1 14. Unit <br />G <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, <br />pocked, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <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 I have determined to be <br />economically practicable and that 1 have selected the practicable method of treatm e, or disposal currently available to me which minimizes the present and future <br />throat to human health and the environment; OR, S 1 nm a small quarntity ge error, I have n1hk a grdfaith effort to minimize my waste generation and select the best <br />waste management method that is available to me and that I can afford. <br />F <br />A <br />C <br />1 <br />t <br />1 <br />T <br />Y <br />Printed/Typed Name <br />Signature <br />nrdous materials covered <br />Signature <br />e � <br />DO NOT WRITE <br />Day _ Year <br />Month Day Year <br />Month Day , Year <br />White: TSDF SENDS THIS COPY TO DTSC^WITHIN 30 DAYS. <br />.Printed/Ty Name <br />_ped <br />T <br />R <br />17. Transporter 1 Acknowledge <br />A <br />S <br />acme r <br />Prin V7 <br />0 <br />18. Transporter 2 Acknowledgem <br />A <br />T <br />Printed/Typed Name <br />E <br />A <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />t <br />1 <br />T <br />Y <br />Printed/Typed Name <br />Signature <br />nrdous materials covered <br />Signature <br />e � <br />DO NOT WRITE <br />Day _ Year <br />Month Day Year <br />Month Day , Year <br />White: TSDF SENDS THIS COPY TO DTSC^WITHIN 30 DAYS. <br />