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Oct-29-2004 01 :59 From-CUST SERI* + T-169 P 002/D04 F-255 <br /> I <br /> State of California—E'ramseniol Prollacrion Agency . <br /> Form ApprovedOMa No.20$0-0039(E pires9.30.99) dile 1n3trUCtltill8 on h1IICk of page 14. <br /> PFeosa print or type, Farm designed for me en ultra f l7•plrchJ type.vrlMr. Deporfnent of Texie Subslanee.Cxlrol <br /> AL Saeramn.lo,Calilornle <br /> UNIFORM �OUS11. Genaralor's US EPA ID No. 1s4onifesl I)aarmanl No. 2. Page 1 Information in the shodod meas <br /> WA5TE ST ff Ir nal required by F&dmol Ia.r, <br /> CAL 0 0 0 0 1 Q 9 1613 6 � sG +,� o, <br /> 3. Generator's Noma g Address - - <br /> A. Slate Manifest Docereenr N saber <br /> ldstale¢I$g Of$tocketin r}C + <br /> a 4137 S. Stockton Street L <br /> 6525 <br /> StoOrt 0. Stare C—rarce's 10 <br /> to 4. Generalor's Phone f � t A 9S�f}G <br /> N 5. Trarwporter 1 Camaorty Mame <br /> "' d. t!5 EPA ID Nuaber ,� <br /> ao ROMIC Environmental Technologies C. SID aTran:Parter'sID[Rerened.l <br /> 6 <br /> mLn F 7. Transporter 2 C.smporry Name 0. Transporser's—Phone <br /> IT. US EPA ID Number E. Stow Transporfds A IRs ired.l - <br /> R!e�¢� <br /> Ln;U F. Tretrsspmler's Phone <br /> ....,� 9. Designated Facility Name asd Site Address 1 D. US EPA ID Number G. State Fail <br /> ROM1C Environment"technologies lyafD <br /> 20111 Bay Read COLVI 4151 2 615171 <br /> H. Facility's Phone <br /> East Palo Alto CA 94303CAD 0 0 9 4 5 2 6 5 7 85101324-1638 <br /> _ <br /> 11 US DOT Description[including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. iota[ 14. 'Jolt <br /> Z o No, T Pa puo•nYi WI/Vol I. Waste Number <br /> Other regulated substances, liquid N.O.S.9 'rate 3 3, <br /> E NA 3082, P©HL RQ, Contains Ethylene Glycol � �7,�� � � �- EPA/Cther <br /> @ b. <br /> o N - <br /> m E Slate <br /> v <br /> EPA/Olher <br /> A <br /> d T <br /> m 0 State <br /> rr � <br /> EPA/Other <br /> Lu Fd. <br /> P- <br /> Z State <br /> w <br /> V <br /> w EPA/011ier <br /> Z J. Additional Descriptians ter Melerials listed Above <br /> a� E lens a. Handling Cedes for Wastes I slid Abore <br /> Gwen u•7��1 a. 01 I.. <br /> (Antlfreeze) <br /> © IS. Speciol Helldlirsg Instr.retfam and Additional Information <br /> Glares and Protective Ciothiing Emergency Response Phone B#}01T66 d2d8 <br /> Z ROM 10 Profile#201111 <br /> � Emergency Response Gude Book #171 <br /> 15, GENERATOR'$ CERTIFICATION; I hereby declare that the :wlfersts of this consignment are fu1Fy and accurately doscribad a6a.rs by proper!hipping man a and are classified,pocked. <br /> marked,and lobated.and ore In all respects in proper condition for transport y highway cecording to applicable,nl'no=ua and nalicino govemr mnr regulations. <br /> -.i <br /> a+ IF 1 em a large quonti genaraicr,i certify thnt I haw a ra ram m <br /> p place to rodute the.alums and toxicity of waste generoled to the degree I ha•a delrurmined toThe economlcol[[yy <br /> practicable and Thal I ave seleclad the practicable method of ttmalment,storage,or disposal currently available 10 me which minimizes the prosant and Future threat ro human healrfu <br /> O and tiro environment;OR,if I am a sm-A quantity genismim,I hove nada a good&sins effort to minimise my waNe generation and saFrct the best,rode management melhad Ihot is <br /> available to me and Mw t can afford. <br /> } P rimit 1 Nara Signghma MonthDa Year <br /> Z r� -, <br /> W T ~� <br /> R 17. r crier lemorli of Racal 1 of Materials <br /> w M Pnnted/TYP/,Name Sign ur • Menlh Do Yaa� <br /> sL 0 1 R. Tran rte,2 Acknawled emenl of Receipt oF Materials <br /> 0 , Prinrad/Typed Nome <br /> LU ! lure Mawis Day Year <br /> � R <br /> U F 19, Discrepancy Indication;pace <br /> Z A <br /> C <br /> I <br /> L <br /> F 20,�Paeilitv Owner <br /> mr-Operassar Cerlificatiun of riscAlrill of hazardous mnlmicsls aauered by This msnifmf @sacs t as nosed in Ilam 19. <br /> YPrint d/Typed t�tsmr Signobre r _ Mon!h Day Yeor <br /> C) <br /> DO N07 WRITE BELOW 1'NIS NE. <br /> DTSC 8022A(1/99) .. - "Ur ::'^.0 S ', :(,,I x DIS: 3C DAYS, <br /> EPA 870G--22 !- [; C., 0591�' <br />