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00-29-2004 02:00 From-CUST SEPV0 + T-169 P-003/004 F-255 <br /> 1 9 <br /> 51ale of California—EnvironmenMF Prerecrion Agency _ <br /> Form Approved OMB No.2054-0039 IE:p;ras 9 30-99I 0'� Instructions on i1gCi(p� <br /> Please prinf or type. form designed for are ar eliteV 2,,P hhf rypew6ter. page Frt• Deparfreaw of To=tc Subclone_Contrgl <br /> 1. Generator's US EPA 10 Isla Sacramento,California <br /> UNIFORM tt/ ARDOUS ry maa-'nifesi Demme No. 2. Palle I ktformotion in the shodod props <br /> WAStE MANIFEST CAL 0 0 o a ; 0 9 $ �1• `7_ af�a nor raqu.red by Federal love. <br /> 3. Ganerara:s Name and Mgilfna Address <br /> A. State lr7rIJWtDorumenlN�.mber <br /> 0 1137 <br /> A.8torditon 9trgat L 9 <br /> In 4. Generatols phone($tOcktrdfll, CA 95206 B. State Ge: ram-'.ID <br /> 209 944 p808 ler 1,�rs I� <br /> � $, Tranaporlor 1 Company Name 6. US EPA ID NumberTransporter'. <br /> 'Ki.U11Sti.LJ In <br /> ROMIC Environmerntal Technologies C. 51014 Transporter'.lD lalumYvd,] <br /> 0 <br /> c? D. irdniparle!s phone <br /> 7. Transporter 2 Company Novae - B. US EPA 1D Nrmdser `1 <br /> E. Slate Trars"'w'3 ID[Roar m <br /> C"iV - F. TrQ nspprh <br /> . ar's Phone <br /> P. Designoled Facility Name and Sire Address 10 t15 EpA ID Namber <br /> tWz ROMIC Environment Technologies 01• Slate Fori�lty;1D <br /> 2081 Bay Road CftLD�UL[0 9 14 15 2 16 15 17 <br /> H. Facilily's Phone - <br /> C\l East Palo Alto CA 94303 IC A D 10 10 9 4 5 2 5 5 765QIi'324-'1 B <br /> 11. U$DOT Descrlprioa[ioduding proper Shippin;l Nome,Ftazard Class,end 1D Nambrrl 12. Compliers 13. Tata) 7n. Unll <br /> Z o wtl- Type puontity Wr/Vol I. Waste Number <br /> = Other regulated substances, liquid N.O.S.9 J i Brat° <br /> r <br /> 343 <br /> 3 E NA 3082, PGiill, RQ, Contains Ethylene Qi col l_�L EPA/Olher <br /> oa N b <br /> ' <br /> ca E Stale <br /> 4 R <br /> CNv <br /> EPA/Other <br /> A <br /> o T <br /> m p Stale <br /> -- R <br /> • � r I EPA/pllser <br /> ' d. L—L <br /> T— <br /> Z Stare <br /> w <br /> U <br /> Lu <br /> "A/ er <br /> v) 1. Addirla;;l Dmeriptioas far Maleria�s listed Above <br /> Z K. Handfing Cedes far Waatas Lsled Above <br /> 2 Waste Ethylene Glycol. p <br /> (Antifreeze) <br /> J d <br /> a <br /> Z <br /> (� 15. Special Handling knsmuctlans and Additional lnfarraation '— <br /> Gloves and Protective Clothing Emergency Response 110hone 80017664248 <br /> w ROM IC Profile #201117 Emergency Response (Bustle Book #171 <br /> r <br /> =+ <br /> 76, GENERATOR'S CERTIFICATSONa I hereby declare that the conwnls of this consignmeol me fully and accarglelydescribed above by.p,aper chippingi ram-s and are clorei Fied.packed, <br /> 14.1 marked,and lobeled,and aro in all respacra in proper condition for manspon by highway orcarding to applicable inlemotianal and lotioiw governm�nl regulations. <br /> J <br /> OIL IF I am a largo gaontity generator,1 wnfly tf�d I kava a progrq in place to reduce the,lone and toxicity of waste geaergled io the degree I hm;deiermi rod io be economiccollyy <br /> vs proclicable and that I=selected The practicable methal of lreatmeM,garage,or disposal ftmenty o,molsle to me-hich rri nirnizea the pro asd lature threat!o hrrmon heaNh <br /> oe and she environment;.OR,if 1 am a areoll quorstiry rnera lar,Ihave made a good faith effort to rain:mite my ste gene; gn ar,d sele:t the best wsste management mefhod 0,or is <br /> Q available to ma and r I can afford. <br /> Y Printed/Typod Nome S9�w de <br /> i atvra —� Manch Day Year <br /> Z dW ✓.is!/lx ✓ .. - it l s >• <br /> R17. hon, erre,1 Acknowled ement of Recai of Metarals C <br /> ,11 JI <br /> ne <br /> N Pnnledl yped NomeLc � <br /> 5ignatvr>r� - Manch Pay Year. <br /> rx <br /> 0 1 B.STrans over 2 Acknowled errant aF Recai sof Materials_ - <br /> i Printed/Typed Name Sign , <br /> LLIMonth Day Year <br /> Q e <br /> V F 19, Discrepancy indication 5poce <br /> A <br /> C <br /> F <br /> L <br /> 120. Focili Owner or Operator Cart;' of repel i of hemordws mater els covered tAis mans fes4 ax m Waled in Iren 19. <br /> I Printod/Typed Nome Signolure Month Day Year <br /> Y - <br /> DO NOT WRITE BELOW THIS LINE. <br /> PT$C 0022A I1/991 <br /> EPA 17700-22 s - �. :�• i - <br />