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State of Coliform.—Environmental Protection Agency 185-01. <br /> Form Approved OMB No.2050-0039(Expires 9-30.991 See Instructions on back of pa� Department of Toxic Substances Canrraf <br /> Please print or type. form dasigrred for use on o-l`h f 12•pitchJ "ler. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document Na. 2. Page 1 <br /> Information in the shaded or <br /> WASTE MANIFEST C AR OOO 118182 # 5f E5 is not required by Federal low. <br /> of <br /> 3. Generator's Name and Mailing Address W t A. State.Manifesl Document Number <br /> RONQIMPERIAL D r 22133832. <br /> CA 95376 Stain Generator'sol) <br /> A. Generator's Phone 12091 1220—18 15 <br /> .IN 5. Transporter 1 Company Name 6. US EPA ID Number <br /> LO C ;Stole Traosporter's'.iD'f Reserved.] <br /> o SAFETY—KLEEN SYSTEMS, INC SCROUO47515 D. Transporfier'sPhone <br /> _ 7. Transporter 2 Company Name E. State Transporters 10[Reserved.] <br /> P P Y <br /> B. US EPA ID Number <br /> J <br /> _. Tranfperter's Phone, <br /> Cn U F ty on ! 1R US EPA ID Numbs, 'G''Stale1ocil, 's-1D' <br /> MS, INC M - 6040 88TH STREET ' <br /> eQCQ 1X SACRAMENTO CA 95828 CA0000084517 H. Facility:s Phone <br /> �- 916 386-4913 <br /> Q 1 I. US DOT Description(including Proper Shipping Nome,Hazard Class,and 1D Number 12. Containers 13. Total 1 d. Unit <br /> V p ( g p pp g I No. Type Quantity Wl/Vol I. Waste Number <br /> HAZARDOUS WASTE, LIQUID, N. O. S, DE state..13+4 <br /> 9 NA3082 PG III (DO39) (ERG#171 ) EPA/Other <br /> 3 G AQUEOUS BRAKE SOLUTION(B. 3#/GAL) r <br /> E D439 <br /> N <br /> OaaN b' State. <br /> co E <br /> V R EPA/Other <br /> 4 A <br /> 6T c. State <br /> 00 O <br /> R EPA/Other <br /> oc <br /> UJ H d' State <br /> Z <br /> u.t <br /> U EPA/Other' <br /> LU <br /> z <br /> J. Additlonof'Descriplions for'Materiais I-istedtAbave K. Handling Codas.for Wastes kisted Above <br /> O o. 14 b. <br /> LU <br /> c. d. <br /> a <br /> Z —�69- 764 24HR <br /> Z <br /> 5K AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIER, AS NECESSARY. <br /> F A 839 B C D <br /> 16 GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelyy described above by proper shipping rome and are classified,packed, <br /> marked,and labeled,and are in all respects in proper condition for transport by highway according to applicoble international and nalionol government regulations. <br /> J <br /> If I am a large quantity generator,I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> N practicable and that I hove selected the proclicoble method of treatment,storage,or disposal currently available to me which minimizes the preserl and future threat to human health <br /> and the environment;OR,if f am a small quonliy generator,I have made a gaud faith effort to minimize my waste geraraSan and select the boil waste management method shot is <br /> 0 ovailable to me and that I can afford. <br /> a <br /> y Printed/Typed Nome 5i8nalura Month Day Yeor <br /> R17. Trani orter 1 Acknowled emenl of Recei prof Materials <br /> W { Printed/T ped Nome Signatur Month Day Year <br /> � R - <br /> u. O B. runs aster 2 Acknowled ement of Recei t of Motenals <br /> Q T Printed/Typed Name Signolure Monfls Day Year <br /> W E <br /> to R <br /> -Q <br /> Cl 19- Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> f. <br /> 1 20. Facility Owner or Cperatcr Certification of receipt of hazardous materials cover ani s tet noted i It 19. <br /> T ed/Typed Name Q ! Sign me Mont Do Year <br /> Y <br /> NOT TIS hbV <br /> DT5C 8022A 11/991 White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 To: P.O. Box 3000, Sacramento, CA 95912 <br />