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_ l <br /> Please print or type.(Form designed for use an elite 12-I(Ch) wrilec Form roved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Garemla tO Number " 2.Page l Of 3.Emergency Rwpnu Phow 4. an est Trac Humber <br /> WASTEMANIFEST CAL000269375 1 (600)424.9300 011827260 JJK <br /> 5.Ganombys Name and Maftluddiess Genarab(sSlWAddmss(if Mount then mafirg address) <br /> PICK N PULL#80 <br /> 3827 CLARK DR 3927 CLARK DR <br /> STOCKTON CA 95205 STOCKTON CA 95205 <br /> Genembes Ph", I <br /> 0.Transporter 1 Company Name U.S.EPAID Number <br /> LSERV AD02 2 7036 <br /> 7.Badapoder 2 Comparry Name U.S.EPA.61277036 <br /> O Numbe <br /> S.Designated Facility Nameand SileAddress <br /> U.S.EPAID Number <br /> DK DIXON i <br /> 7300 CHEVRON WAY <br /> DIXFacill ass PPhh": CA 86820 _ A T 0 8 0 012 6 0 2 <br /> ger, and pactmg Doup(itm(NMtbg Proper Shypbg Nana,Hazard Gess,N7 Number, D.Contalrien <br /> HM and Fackfig Group(d my)) "-TotalNo, gyps Camby yWA,d. M.Wesle Codes <br /> I <br /> 0 1NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL 001 FT G 133 <br /> SOLUTIONS) / — - <br /> a 2. <br /> w <br /> 3 ' <br /> I <br /> —I I <br /> 14.Spedal Handling Instructions and Additional Infonmadon <br /> NAERG# 981:17i s'PROFILE#961:OKi00i83***EMERGENCY CONTACT.CHEMTREC 1-800.424-9300 <br /> ADDITIONAL EPA CODES;981:.NONE a APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> OV/0711/ <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:Ihaebydedare gmtMwnlenteaflNsaxui mare MOyaxiawureleydeaxlbedabove by Ne propershlppipq rama,all are classified,packaged, <br /> marked and WheWpfecaded,and are In of respects N propocg itimr for aampodaaordag to applicable kaerradoneland nalsDadgowmnrenlalmoulatons.if expodship ant and Iom the Primary <br /> Exporter.Iremy tlutft coden6 a18ds amsigmrent wham to the terms of the eftedred EPAAckaxfedyw(uf CatsenL <br /> I aNfythalthe waste minimization statement IdKAM In40 CFR282.21(a)glism a large gmnurygenerela)a(b)(fl ama wrap quanNy ganerelo)Is we. <br /> GerarelaralOReroys P' Name Signature MoA Day Year <br /> —r 1S ntema Sh;,menh - <br /> ❑ImparttOU.S. ❑Expxt fiomU Palofenlryyenl <br /> Transporlasgnalure(for exports any); Dale leavurg U.S.: <br /> w 17.TranspalaAtkwMedgwidel Rec*ofMaumes <br /> 12 T iPraxeMYRetlNSgnewre _ Monty Day Year <br /> sJU�C iG QR 7� U <br /> ranspddw2Pdnledylyped Nate nor 9 MOA Day Year <br /> r— <br /> TI&Discrepancy <br /> 18a.Discrepancy bulwNon Space ❑aanw ❑rip. 1:1 Residue ❑PadWRe)ecuen El Full Rcje . <br /> Manifest Reference Mandan:iBD.ANemale FaaTry(or Geamla) U.S.EPA ID Number <br /> i <br /> U I <br /> as Facfdys Phone: <br /> yaF�j 18c ahaeoimmateF yaGenerator) Month Day Year t <br /> Y <br /> S2 19.hazardous Waste Report Management Wood!Codes(La.,codes for haierdowwash,basement,disposal,and recycing sysrsms) <br /> G 1. - 2. 3. 7- <br /> 20.DeslgmWd FwRy Oona a0perebw CediBcegan of malptofhatardaus nreledals canoed by the mau fest except as noted In Nem 18a <br /> PER yp ane a s n M" Day Y. <br /> trhouS J O b 13 <br /> E?ARIDD 8700-22(Rev.3.05) Prevlouseditbnsare obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> i <br /> 1 <br />