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i r t <br /> State of Cal ifornio—Environmental Protection Agency <br /> ° pproved OMB No.2050-0039(Expires 9.30'99) See Instructions On back of a 6. Department of Toxic Substances Control <br /> Pl si pnrit or type. Form designed for use on elite(12-pitchJ)�iter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST 4�AD �'�''.`7•`^�•,�?"i 01 0; ;�9 � ' is not required by Federal law. <br /> of <br /> 3. Generator's Name and M -N1 ST <br /> ko LOD 1, CA din Add ess `°'s r � L t 4e°w T T°i A Stpte Mamfes Document Number <br /> 95205Slate Gerreratgr�t tis <br /> 4. Generator's Phone( 209 333 " <br /> . : <br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number G sJate,7ecnSpaFleF s1fIResgrved} 'r t <br /> 00 FsAFE,rY—KLEEN SYSTEMS <br /> O. p TFanspartes's Phoria "1" <br /> Gt 7. Transporter 2 Company Name 8. US EPA ID Number E State Tr ns rte{s tD Reserved. <br /> P p Y P fm EI ; <br /> q F. Transporter's Phone <br /> +m.,.V D srgnat r mnd to ddr ss y re.f 10. US EPA ID Number G. State Facilt <br /> Q , , t„' rs xJC <br /> �✓ <br /> Z <br /> o! _>.:'.. H. facility's Pho e _ <br /> J <br /> 'i < 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> "i UNo. Type Quantity Wt/Vol 1. Waste Number <br /> Z a. a ._ <br /> ll,rs �3 iDI r Sat a�w �z F x'"§ YL r.'.��ts State c <br /> t_— <br /> (NOT M�. '�V X00 Y {Te 2,d�,BL—A 4,t D) �i«74.� 1.6}t'•'•4 .+-, F r' <br /> 3 G y EPAfOth <br /> E <br /> C;4 <br /> N b. ,State 2 <br /> poo. E Ftfr " <br /> y Rf*Af tPier: <br /> C14 A <br /> b T <br /> CD O <br /> R EPA�Othar <br /> Cie <br /> W d. , <br /> Z. <br /> EPA/OtheF: <br /> 1. Additional escri tions for'Materials Listed 4bove <br /> l p k. ft Ing Codes for Wastes Listed'A7sove <br /> a. b. <br /> W <br /> c d' <br /> -41 <br /> 1760 24HR, <br /> Q SKUfHORIZED 3O RETAIN L-ICENSED SQ13S G x: 114'* AS <br /> Z <br /> LU A 112 49 ? s' <br /> 16. GENERATORS 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 /> ' <br /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> -J-r If I am a large quantiygenerator,I certify that l have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> d practicable and that lave 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 and the environment;OR,if I am a small quantity generator,I have made a good faoh"i4ffort 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 /> V <br /> Month Day Year <br /> Prime yTyped Name Signatufr¢' ! �y <br /> Z <br /> t 17. Transporter 1 Acknowledgement of Rece' of Materials <br /> R <br /> LU A Printed ped N e Signature :' Month Da Year <br /> Y <br /> ,",F�"� p9 .,+. .r �• .�.�� .. .,,ate.,._,.._... .... ... <br /> LU P hI C �f" .r �j,iW atm _ rr-° &. ..t a. <br /> Ll- a 18. Trans orter 2 Acknowled ement of Racer t of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> u:t E <br /> N ;R <br /> U19. Discrepancy Indication Space <br /> C <br /> I . <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered Mihis manifest except as noted in Item 19. <br /> Printedrys ped Name Signature r�`< Month Day e <br /> Yay� <br /> . e <br /> eAl <br /> / DO NOT ITE BELOW THIS LINE. <br /> DTSEPA 9700-00-22(1/99) <br /> EPA Yellow: GENERATOR RETAINS <br /> . 87 <br />