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FrOrn:ZMT, Inc Page: 7/7 Date 114!2012 11:09:00 AM
<br /> 7142
<br /> Please print or type.(Form desigped for use on elite(12-oRrh) ewrite-)
<br /> Form Approved,OhiB No.2054-OG3A
<br /> UNIFORM HAZAR00U$ 11.Ge"'MrIONumt T 2.Pa 1 of 3 Em�r�e m! a p ase 7 2 4.Manlfnat Tracktrtg Number
<br /> WASTE MANIFEST CAL000.ti25362 —tiN�—Igg 410 003731042 m F
<br /> .� 5.Generator's Name end Wiling Addms9 enemlo"3 SiteAdtl 9s (If dl emnt Iran mad ng adtlress)
<br /> ZM TECHNOLOGIES
<br /> 1010 SHAW RD
<br /> STOCKTON CA 95215
<br /> Gennmto13Phw,a; 2m9-547-1955
<br /> o. rape^o^.er 1 'ompen ems U.S.EPA ID Num 19r
<br /> SAFETY IN'I SYSTEMS, INC. TxR�I�Q�►5693m
<br /> 7.TransCon?r 2 Company Nama
<br /> J,S,EPA ICIN�unhnr
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<br /> TAI'P122' APA d,Uenlgno TO FarlIlly Name and SI IP.Addrfs5SAFETY—KLEEN SYSTEMS INC. u.7lD Number
<br /> 1722: COOPER CREEK R04D
<br /> bENTON, , 7X 762(b&
<br /> 940-483-5200�adllty's Phono; TXD07760337I
<br /> ga, 5b.1.13,DOT Joscrptfoo(including Prapv Shipping Name,Hazard Chs,-,IG Number, 10,Conivnera 11,Total 12,Unit
<br /> ,IM and Paaing Gm'up(if any))
<br /> Na, Typo Ouanlily NN,NpI. 13.'n'asla Cpda3
<br /> X 1. RQ WASTE FLAMMABLE LIQUIDS, N.O.5� DM p D@01 c14
<br /> a (P--GHLORCEENZOTRIFLUORIDE) UT5
<br /> Uj 3 UN1993 PG III (D001)
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<br /> 1E,sandal Handling Insnuctons and Addlnona!Infofmation SK
<br /> 3142935 CSG:
<br /> I)ERG#128
<br /> 24 HR EMERGENCY 01-800-468-1761 (SAFETY—KLEEN — 94138)
<br /> 5K AU 'R T12 USF—SUB-SEQUENT CARRIERS:41-16,78.41471,al
<br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION;I hereby declare that the contents of Ihls cons!gnment am fully and amlrately described above by the oroperahl In name,and ua alasslFfd,packaged,
<br /> marked and labaledrplacarded,and are In 111 rrsp ct In proper cordflion for hempen according to Applkable intemntiana(and nailOnal govpmmenlal ragulallons.it szopn ghfpmomt and i am the pdrsry
<br /> Exporter,I csrflfy:hat the contents of Ihls consignment conform to the forma of;ha MOM EPA Adknmvledgment of Consent.
<br /> I certify hitt the waste minim).+;ion vmwant Identifled In 40 CFR26217(a)ON I am A large Gungtity gener3lcr)Or%; : A sne11 qunnRy genoMIor)IS time.
<br /> gar Ator s lI erer's nted yp Name ,gna ro
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<br /> 1 1 B Intems0wal Shipment& I�
<br /> _l Import to U'S' �I Exparl hem U, Port of Oaf ;ezft;
<br /> — craps ortor aI a;urr. fcr fx ens an: Oa!e Ie�uir U.S.:
<br /> TransportarAcknowlndgment of Receipt mf Materlals
<br /> Trans arter 1 Pdn ed,Typed Name ;Ign-Mum
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<br /> neponer 2 NffiledffyIped Name 5;gn
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<br /> 14,Discrepancy 4"
<br /> 18a,Discreosncy I,dkabon Space Quarllry T �I
<br /> vFg I__I RrtsidUo ❑Paella!Rejection I-..,.1 Rdl Rajsctfan
<br /> 1Ah,Alternate Facility{or Generator}
<br /> A?anl'Pst Rafe encu Nu on
<br /> U.Z.EPA Ib Number
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<br /> Uj� FacIIIN's PSOh:;
<br /> 18c.Signature ofAl ema19 Facility(or GenoralM) ` . .
<br /> k" Month Day Yeaf
<br /> Hazardaus WmIa R ort 6fan, omont m4f al Coda-'.o.,codnq or f!aza*dom wa
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<br /> 20.0.r a Facility Omer of Ooaralor.CedllIcaban of mceipt of haznrdous mst�rlll!t Covered by the manifest axr�pt a rte m Itam 18a
<br /> P /Typ Name Q SIAhaNre
<br /> C7� Month Day 'leer
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<br /> :IAF0-Q221(4 v 0�5�g4 vlous edilions ar®obsolete. DES TED FACUTY TO DESTINATION STATE(IF REQUIRED)
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