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Stale of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-94) See Instructions on back Of page 6. Depaament of Toxic Substances Coanr <br /> Please prim or type. Form designed for use on euro(121pitch)"writer. socrom neo,California <br /> UNIFORM HAZARDOUS 1a. Gene c 's US EPA 1D No. Manifest Document No. 2. Page 1 nfonnes.in the shaded areas <br /> is.sot required by Federal law. <br /> WASTE MANIFEST 9 7 O 21 } err 1 <br /> 3. G�eEn,e,rator's Nana pnd Mailing Address A. State Manifest Document Number <br /> lslr�''�0n,/ (lu4rCv o�,S 93697024 <br /> �!o S �1�forfWy�Y St�(k�� a a. State Ganeraror's ID _ <br /> N 4. Geraral Phoma (209) IQ.2 �yA���eI#IYW4134 100 If it 17 111 <br /> S. Tromporter 1 Company Name 6. US EPA ID Number C. State Tran sportr's ID 4( —?/3v � <br /> E ASBURY ENVIRONMENTAL SERVICES 77 artere <br /> D. Transpphone --r .(310)886-3400 <br /> I 7. Transporter 2 Company Name 8. US EPA ID Number i E..SMte Tramponer's ID <br /> i < I <br /> -transporter's Phone <br /> i <br /> 1 41* :5 9. Designated Facility Name and Sim Address 10. US EPA ID Number G, Stara Focifity's ID <br /> t <br /> NZ <br /> W <br /> ¢¢' DEMENNO/KERDN IIT�4181�I� 1�31315L`1 <br /> H. Faalit�s Phone- <br /> 2(100 N. ALeNF.it; :T. !'ONPT(iN, Pl ?022, T (310)537-7100 <br /> U Careairmems 13. Total 14. Unit <br /> Z 11. 115 DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12.iT Quantity Wt/Vol 1-Waste Number <br /> `fix "'Ethylene glycol nun-RCRA X135 <br /> 3 G Hazardous waste liquid No Placard Required O 1 91 TT O G te <br /> WA/ r <br /> c; E <br /> N b. Sure <br /> E @ <br /> r R A/ahem <br /> Ta Sore <br /> aP O <br /> R EPAlOther <br /> ge <br /> t H d Stile <br /> Z <br /> W <br /> U EPA/Other <br /> - W <br /> ZJ. Addhorwl Descriptions far Materials Listed Above K. ffadlirg Codes for Wastes listed Above <br /> d0 ETHYLENE GLYCOL 20%-40% b. <br /> W WATER 79%-55% ERGA31., <br /> J <br /> MOTOR OIL 01%-05% a. ,, ..., <br /> I <br /> Z 15. Special Handling Instructions and Additional Inforni <br /> EMERGENCY RESPONSE CONTA( r: <br /> Z GLOVES & GOGGLES 24 HOURS <br /> W <br /> { � 16. GENERATOR'S CERTIFICATION: I hereby declare that the comems of this consignment are fully and accurately described above by proper shipping eame and are classified, <br /> pocked,marked,and labeled,and are in all respech in proper condition for transport by highway according to applicable international and national government regulations. <br /> Q <br /> V <br /> � If I am a large qua"generator, I certify that I have a program in place to reduce the volume and toxicity of warn generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatmem,storage,or disposal currently available to me which minimizes the presets and future <br /> I N <br /> threat ahh at to human heand the environment;OR, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste generation and select the best <br /> wore management method that is available ro me and that I can afford <br /> Ad <br /> 0 rimed/Typena d NaSig Y <br /> T 17. Transporter 1 Acknemm <br /> wled eeof Receipt of M serirsh <br /> k Z Prnted/Typed//[�erne Signaturef) Motsdr Day nYear_ <br /> Is <br /> of s <br /> ' 0 18. Tromporther 2 Acknowledgement of Receipt of Materials <br /> W j Printed/Typed Name Signature Mamb Day Year <br /> LL. Fkw tell <br /> p <br /> R <br /> l W 19. Discrepancy Indication Space <br /> N <br /> F <br /> U <br /> U A <br /> L <br /> 1 20. Facility Owner or to <br /> ror Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, <br /> T Printed/Typed Nome Signature Alnmek Day Year <br /> y i� <br /> DO NOT WRITE BELOW THIS UNE. <br /> DTSC 8022A (9/93) ENERATCR <br />