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Form Approved OMB No. 2050-0039 (Expires 9 30-99) See Instructions on bad Page 6. Department of Toxic Substances Control <br />Please pnrV or type. Form designed for use on elite (12 p ,pe writer , <br />Y <br />O <br />LO <br />L0 <br />CV <br />V) <br />OD <br />O <br />O <br />00 <br />0 <br />00 <br />ao <br />v <br />N <br />v <br />6 <br />O <br />00 <br />Cc <br />LL <br />Z <br />LL <br />I- <br />LL <br />V. <br />Z <br />C <br />a <br />N <br />Ce <br />Ce <br />a <br />Z <br />C <br />H <br />a <br />z <br />LL <br />a <br />L <br />n <br />V <br />C <br />L <br />2 <br />LL <br />LL <br />C <br />LL <br />LL <br />LL <br />V <br />a <br />L. <br />t, <br />/ DO NOT WHITE BELOW THIS LINE. <br />Lr a :i. ; �i- -,'PY T3 GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (1/99) -I � - i,m" 'i,i7t ri us waste for transport out-of-state, <br />EPA 8700-22 u' 1. Iii .I 0 copy and send to DTSC within 30 days.l <br />UNIFORM HAZARDOUS <br />I ' Gen rator's U5 EPA ID No <br />Manifest Document No <br />2 Page I <br />Information in the shaded areas <br />WASTE MANIFEST <br />;� ] ". <br />s not required b Federal law. <br />q y <br />i <br />of <br />3. Generator's Name and Mailing Address1. <br />F, E j, <br />A. State Manifest Document Number {� {� <br />13 N A7 11i `T RD.�7 <br />1756 9 <br />TT14 E1; CHC,FfiER <br />B. State Generator's ID <br />rP�AUL <br />la��(1xe�ert�tol' hone,( 1- A :) 5 - <br />4, ': <br />�a t <br />5. Transporter I Company Name 6 US EPA ID Number <br />C. State Transporter's ID (Reserved.] <br />AF �'7'Y KLFEit S'ia'T@;1"lS, INCT � 9 C tj <br />1 )� <br />D. Transporler'sPhone <br />7. Transporter 2 Company Nome 8 US EPA ID Number <br />E. Stale Transporter's ID [ s 'd.] <br />c <br />AFE "f• Y .- i', L E :: N \ -'- `i 11\11.. _ P 1� 1� ] 1. '! <br />1 U A 1 1 1 <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10, US EPA ID Number <br />916 <br />G. State Facility's ID <br />000"'6p <br />A 00 4 45 7 <br />SAFETY—KLE:E:N <br />SYSTEMS, Ii -1C. <br />H. Facility's Phone <br />000 88TH STREET C: tCA <br />95629 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number[ <br />Containers <br />No. <br />No <br />13. Total 1'4. Unit <br />Type Quantity Wt/Vol I. Waste Number <br />a. <br />State <br />HA7ARDOi;; WASTE L,c�IIJI!, N ^ ;; <br />G <br />9 NA30A2 P II i ( flit'(`) ` � �'f�a� LC i'' <br />^fir f <br />iI'" <br />�'� ;�1'� <br />EPA/ her <br />N <br />b" <br />State <br />E <br />R <br />EPA/Other <br />T <br />C. <br />State <br />0 <br />R <br />EPA/Other <br />d <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b. <br />15 <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />MF <br />S T R / "r' iN C)8`-; !,`5 'i.! s 0001 -;5's 1--'.-'2 <br />MERGE14CY RESP Hit 1. IF <br />TJNIDE(IVE`Afls J.: Ecr:rl'' ItN TC; GENERATOR. <br />K CORP AUTfH0R1ZED TO RFTAlN i.IC:ENSE V. <br />SUBaEQ1)ENT' 1" PK,II—RS FSS NEC:ES:�ARY <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the core o t is ons, nment a <br />cc Lely described above byproper shipping name an are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport y highway <br />according to applicable international and national government regulations. <br />If I am a large quantity generator, I certify that I hove a program in place to r(duce the <br />I have dinsal <br />volume and toxicity of waste generated to the degree I have determined to be economically <br />the future threat to human health <br />practicable and that selected the �racticoble method of treatment, storggle, or currenVy available to me which minimizes present and <br />and the environment; OR, if I am a small quantity generator, I have made a t, god foith.Jtb <br />to eirymize my wc�Ve'gaperotion-and_ select the best waste management method that is <br />available to me and that I can afford. I i 1 <br />I "'-j." <br />Printed/Typed,Si <br />ame (' I .. _ <br />ta•, <br />R� I of-- \ <br />Month Dgx,,7 Year <br />T <br />17. Tro s orter 1 Acknow ed em nt of Recei t of Materials <br />R <br />A <br />Printed/Typed-dame <br />Signatu <br />C t �� <br />onth Dcrq Year <br />,' <br />P <br />18. Trans er 2 Acknowle ement of a i of Materials <br />TE <br />Print y d Name <br />Signature <br />L <br />Month Day Year <br />--// <br />\ <br />19. Mcrepancy Indic ion Space <br />P <br />I <br />A <br />C <br />I <br />L <br />20. Fac'fit Owner or Operator Certification of receipt of hazardous materials covered t is manifest except as noted in Item 19. <br />j <br />ri d/Typed Name <br />Signotur <br />T r <br />Month Day Year <br />/ DO NOT WHITE BELOW THIS LINE. <br />Lr a :i. ; �i- -,'PY T3 GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (1/99) -I � - i,m" 'i,i7t ri us waste for transport out-of-state, <br />EPA 8700-22 u' 1. Iii .I 0 copy and send to DTSC within 30 days.l <br />