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St;-to Calif,,m�ironmerdol Protection Agency ✓ <br /> Form Approved OMB No.2050-0039(Expires 9-30-94) See Instructions on back o. ge 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(I itch) miter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST r . lo V A of 1 <br /> 3. Generator's Name and Mailing Address <br /> inSANBORN CHEVROLET s. state Generator's Ali: <br /> 1210 SOUTH CHEROKEE L NE LODI , CA 95240 <br /> Ln 4. Generator's Phone ( ) s t f 3 <br /> b. US EPA ID Number Sf�afW Ttarpspartefs'ID- ,�y /`� <br /> 5. Transporter 1 Company Name <br /> 00 ANTIFREEZE ENVIRONM TAL ERVC. CAD 9 8 1 6 9 4 8 8 4 �'°°ap°`'"'�' '°n '� 4161325 <br /> 8. US EPA ID Number <br /> 7. Transporter 2 Company Name <br /> E,-Sate�rpnsporterg ID_ °`' <br /> U F. Transporter's Phone <br /> (�Z9. Desi noted Facility Name and Site Addr ss 10. US EPA ID Number (G. State Facility's ID <br /> Z 43� JC ENVIRONMENT TECHNOLOGIES <br /> O 2081 BAY ROAD H. Facility's Phone <br /> a <br /> EAST PALO ALTO, CA CAD 0 0 9 4 5 2 6 5 7 41.61324.10% <br /> U 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper S ipping Name,Hazard Class,and ID Number) No Type Quantity Wt/Vol I. Waste Number <br /> Z State <br /> F 11'�'f l.L_NM GLYCOL ''CLUT:ON (<50r,'b) <br /> t; NON-RCRA 8 WASTE, U QUID 01011 T 7 C9/ 0 EPA/Other NONE : i <br /> c� E State <br /> c N b. - <br /> OP E EFA/C>ther <br /> c4 R <br /> A State <br /> T C. r �_ <br /> O EPA/Other <br /> R <br /> LU State <br /> l'- d. <br /> Z EPA/Other'. <br /> U <br /> w <br /> N �I( H.ndli-q Codes for Was vb �v <br /> Z J.Additional Descriptions for <br /> materials list Abovd '' <br /> d <br /> WASTE I NYN ' tI.� TI� � a. 'j <br /> ;.� b. <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> GLOVES ANO PROTECT E CLOTHING EMERGENCY RESFONSC fel-IrysE 4i6f3Z�4-iG38 <br /> Z <br /> LU ROMIC PROFILE #20111 h <br /> X <br /> 16. GENERATOR'S CERTIFICATION: I he by declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> pocked,marked,and labeled,and are n all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> Q <br /> U <br /> If I am a large quantity generator, I c rtify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be <br /> economically practicable and that I ha,e selected the practicable method of treatment, storage, or disposal currently available to me which minimizes.fYie present and future <br /> a threat to human health and the enviro ment OR, if I am a small quantity genera I have made a good faith effort to minimize my waste genetatign and select the best <br /> waste management method that is avail ble to me and that I can afford. <br /> Signature M nth 1Day Y pr <br /> Printed/Ty ed N/�',S <br /> Q ��'IC <br /> U T 17. Trans orter 1 Ack wled ement of Rec i t of Materials <br /> Z t: Signa nth Day Year < <br /> LU A Printed Tamped Nome <br /> �� L <br /> W s <br /> P <br /> 18. Transporter 2 Acknowled ement of Rec int of Materials / Month Day Year <br /> LU T Printed/Typed Name Stgn re <br /> LL E <br /> O to <br /> sy 19. Discrepancy Indication Space <br /> N ' <br /> Q F <br /> U A <br /> C <br /> Z I <br /> L <br /> I 20. FacilityOwner or O erator Certificotio of recei t of hazardous materials covered b this manifest except as noted in Item 19. <br /> Month Day Year <br /> T Printed/Typed Name Signature <br /> '! NUKE PORTER <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: GENERATOR RETAINS <br /> OTSC 8022A (9/93) <br /> EPA 8700-22 <br />