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... ............ <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of ge 6. Department of Toxic Substances Cm <br /> Please prod qr type. form designed for we on elite(12-pitch) -icer. <br /> 11 r�se Sacramento,Culifomio <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Pae 1 Inlormmion in the shaded areas <br /> UNIFORM HAZARDOUS g <br /> WASTE MANIFEST f'A 2 u 4 ( G s not required by Fedatallaw. <br /> lie.,. aI .,. <br /> 3. Generator's Name and Mailing Add., HELENA CHEMICALS A.SidteMadilavDocument Number ^� <br /> 2245 W 'CHARTER WAY 21471235 <br /> ATTN WAY14E KITSUDA NT{)C1CTOB. State Generator,IT)PN CA 95201 <br /> n a. Generorore <br /> PP CA 465-5777 <br /> N 5. Transporter I Company Name 6. US EPA ID Number Po I_.) <br /> m C.-SmteTrans Hers ID'Reserved <br /> I <br /> o S&IPETY-KL,LEN SYSTFIMS , INC a :T{ D 7r ( D Tranaporm,'sPhone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E Smte Tronsporter's ID Reserved:. <br /> UE Tmnsperter's Phorle <br /> 9. Desigrmted Facility Name and Site Address 10. US EPA ID Number G. Stale-Facility's ID <br /> .�Z 0513144 <br /> SAFETY-KLEEbl tSAN JOSE ) , I <br /> -414 1021 HERRYESS RD t AA 5? �4�3, H Facility,Phare <br /> �'{Q 11. US DOT Description mcludin Proper Shipping Name,Hazard Class,and ID Number) N_ Conminera 13. Total 14. Unit , <br /> V P I' 8 pe ppi g I No. T e Quantity Wt/Vol J. Waste Number <br /> �Z a <br /> Stele <br /> WASTE ORGANOPHOSPHORUS 8ES'lIC2DES, « <br /> 3 G SOLID TCtXIC { DISULFOTON) 6, 1 UN27tS3 PG D. P EPq/Other <br /> ( EAG 3 1 1 1 � b <br /> E PG39. <br /> N b' Stale <br /> so <br /> m E <br /> N R EPA/Other <br /> a A <br /> T ,tete <br /> t=-:_g O <br /> R _ - EPA/Other <br /> W d. slew <br /> .Z <br /> W <br /> V PA/Other <br /> W <br /> ZT' K. Handling'.Gddes:farWnsms Listed Above.' <br /> IA): hitt►'# b <br /> W <br /> -s <br /> e. d. <br /> a <br /> 0 15. Sp«tel Handling Instructions and Additional Information <br /> � MIFS'7' <br /> Z EMERGENCY RESP 800- 466-�.1.75t0( 24 HR ). IF UNDELIVERABLE RETURN TO GENERATOR. <br /> W <br /> SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br /> x <br /> 16. GENERATOR'S CERTIFICATION: I hereby d«Ian that B,e wnlenh of Biis mnsignmant are{ally and accurately described above by proper shipping rwme and ase classi0ed,pocked, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations. <br /> -s IF I am a laryp qua by genersaor,I certify that I haw a pro in place M reduce the velums and Toxicity o{wash generated ro Iha degree I have determined to be«onomia.11 <br /> Us practicable and that I haw selected the practicable method of treatment,storage,or disposal currently available ro me which minimizes the present and future threat ro human hwlM <br /> and the environment;OR,IF I am a small quantity generator,I have made a.@ood faith eFfort to minimize my waste generation and select the best waste mon <br /> Oawila6l.m me and that I can afford. agement method that is <br /> y Pri '/i�ped Neem ' ,_t <br /> Signature. I - f Month. Day Year <br /> Z t 1 .? t f :.._.... ! ri �? y <^ r <br /> W 1 . Trans r 1 Ac4nowled ement of Rami t of Materials <br /> RT r:.., <br /> ys N PggJgd(,T Name y sign t r. Month - Year <br /> WS % g` A t l 4.�AK AI !E- 4.✓' w' r f 0� w 0� / <br /> P <br /> O <br /> F 18. Trans te <br /> rr 2 Acknowledgement of Remit of Materials <br /> R Printed/Typed Name signature Montit Day Year <br /> W [ , <br /> R <br /> 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> { <br /> r20. eaili Owneror rarerCertiBmtionofream i of hazardous materials cowrad this manifest as noted in Item 19. <br /> T /Typed Name signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> PR�pg L# <br /> dc Aptc}Os}211GO12 <br /> mst�`Bff2�6.ri/991)Gc702,it.7i7"; <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />