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State of California—Environmental Protection Agency 185-01 <br /> F rm Approved OMB No.2050-0039(Expires 9-30-99) See Instructions OA back of a 6. Department of Toxic Substances Control <br /> Pose print or type. Form designed for use on elite(12-pitch) iter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS CAD0764 01 74118 3 is not required by Federal law. <br /> WASTE MANIFEST of <br /> Aft13. Geeneeratorr''s Name and Mailing_AAddd ss A. State Manifest Document Number <br /> 029 <br /> L OD I CA 95240-4799 B. State Generator's lA <br /> r <br /> A. Generator's Phone(209) 333-3504 <br /> CN S. Transporter 1 Company Nome 6. US EPA ID Number C. State Trans porter's 1D[Reserved,] <br /> a0 SAFETY—KLEEM SYSTE , INC ',�ORO(�()4�'S 1°,5O D. Trans orter's Phone <br /> O P d6il�9� %� 0 <br /> O r <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter s ID Reserved.] <br /> F. Transporter's Phone <br /> V 9. Desi noted Fac'I'ty a and t rrk, INC 10. US EPA ID Number G. StateT0506 <br /> 5050 SAL I DA BLVD <br /> SAL I DA, CA 9536E C AT000613968 H. Facility's Phone <br /> O 209 545-1011 <br /> 12. Containers 13. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> y s V No. Type Quantity Wt/Vol 1. Waste Number <br /> ASTE C BUST I E L I GU 14, RI. O. 8. Stats 1 ; <br /> (PEI ROLE NAPHTHA) NA1993 PGII I ® 0 t 0 C3 01 01g EPA/other . 41 <br /> E (ERG#128)6. 7#/GAL. (A001, OO1 , 39, DO44) <br /> O N b: PASTE COMBUSTIBLE LI UID, N. O. S. Stats �41 <br /> C0 E (PETROLEUM NAPHTHA) NA1.993 OIII RG DM G EPA/ether <br /> vA (0001) 128 (6. 7 /(3L) (0018. 39, 0040) D ® Q d Z <br /> o T C. State <br /> m R EPA/Other <br /> d. Stare <br /> Z <br /> UEPA/Other <br /> J1 A(ddit na C{.I On IOI,L,tted 96ov K. Handling Codes for Wastes Listed Above <br /> LU <br /> 7 � <br /> QZ 00"111"*1141 is 00024% '5307 <br /> t #� + �r`�st �` ' tin=' ' a�i�7662-4HF <br /> Z <br /> LU A 7104 BI 801 C D <br /> z <br /> F_ <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above 6y per 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,1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be economically <br /> CL 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 /> N <br /> and the environment;OR,if I am a small quantity generator,l 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 /> Prints Typed Name Signatur �j' Month Day Year <br /> Z ,C'�✓c j to ® a <br /> US <br /> LULUT 17. Trans orter 1 Acknowled ems Recei t of Materials <br /> R <br /> A Printed/T ed®Name p / Signator (onth Day Year <br /> LU S Y I fr Y rtil 1(S wE �i O (2 F.) <br /> U_ B If Trans orter 2 Acknowledgement of Receipt of Materials <br /> 0 <br /> Month Day Year <br /> T Printed/Typed Name Signature <br /> w E <br /> tri R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z P <br /> A <br /> C <br /> L ' <br /> f 20. FacilityOwner or Operator Certification of recei t of hazardous materials covered YAhis manifest except as noted in Item 19. <br /> Printed/Ty a e +} Si2nalure Month ayetsFr <br /> ' n // <br /> i <br /> MzL 161i it <br /> DO NOT"WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A(1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />