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m <br /> State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30 99) a ::U6 Instructions on back o C 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch rifer. Sacramento,California <br /> 7 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS 74 4 1 2 1 is not required by Federal law. <br /> a WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address INTERLAKE A. State Manifest Document Number <br /> 1029 S SACRAMENTO , <br /> L ODI CA 95240-4799 B. State Generator's ID <br /> A. Generator's Phone(209) 3313500 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.]LO <br /> 00 <br /> � <br /> o SAFETY"-KLEEN SYSTEMS, INC CR 00#3 1 D. Transporter's Phone � <br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> J <br /> �Q F. Transporter's Phone <br /> Ueg <br /> 9. Desi nated FacilityName.and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Q SAF T`�°®�tL.EE 3 SYSTEMS, INC �_. 1"�' * ,a <br /> Z 5050 SALIDA SLw D <br /> SALIDAr GA 95368 CAT 000613965 Facilitl/sPhone <br /> 0 9 545-1011 <br /> 0 <br /> �Q 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> U No. Type Quantity Wt/vol 1. Waste Number <br /> �x aSTE COMBUSTIBLE L.I ID, N. O. S. DM G sfdfe 7441 <br /> (PETROLEUMNAPHTHA) l+3 Al 93, P 1II � —'.,` EPA/Other <br /> 3 (DO01)ERQ#N<1 (6. 7# / ) (D018, DO39, O) <br /> O N b. State <br /> 00 <br /> 00 E EPA/Other <br /> -4CN <br /> R <br /> v A o state <br /> o T <br /> °D ® a ° EPA/Other <br /> R <br /> LU d, State <br /> Z <br /> LU <br /> U EPA/Other <br /> ). Additional Descriptions for Materials Listed AboveK. Handling Codes For Wastes Listed Above <br /> I �A) DO 1 DO (A.) 0040 a. b. <br /> h <br /> 1 <br /> LU <br /> C. d. <br /> Q <br /> Z 15. S ecial Handlin Instructions and Additional"Information 0045 0997 )46J2442 0002415 -97 OV <br /> Ek GENET R£SP#800— 8-1760 2 HR <br /> Q , <br /> Z <br /> _ A 801 B C D <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> IF I am a large quantity generator,I certify that I have a program in place to reduce the volume and foxicity of waste generated to the degree I have determined to be economically <br /> N <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health <br /> and..the environment;OR,if I am a small quantity generator,I have made a good Faith effort to minimize my waste generation and select the best waste management method that is <br /> ce available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature Month Day Year <br /> 0 <br /> 0 B 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> N Printed ed Name ,Signat 1 Month/ DaYear <br /> LU::Es �l > Wn f <br /> LU P t <br /> LL. 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Si nature Month Day Year <br /> LU E <br /> cn It <br /> U F 19. Discrepancy Indication Space <br /> 7= A <br /> C <br /> 1 <br /> L <br /> f 20. Facility Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />