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MB No.2050-0039(Expires 9-30-99) -'L 0Z+7—V:L <br /> r type, Form designed for use on elite(12-pitch) ewriter, Sed' IITstCUCt1011S OO bQC�C Of Q9g (�, <br /> l Department of Toxic Substances Control <br /> UNIFORM HAZARDOUS nerator's US EPA ID No. Sacramento,California <br /> C�tD074&4 90 Manifest Document 2. Page 1 Information in the shaded areas <br /> ' WASTE MANIFEST 2I�333f I is not required by Federal law, <br /> 3. Generator's Name and Mailin Address o <br /> 1029 t4k.F� �"fItil I" S A. StateManifestDocumentNumber <br /> L OD I CA 95240-4799 s ID <br /> 4. Generator's Phone(2 91') 333-3500 B State Generator <br /> 5. Transporter 1 Company Name <br /> 6. US EPA ID Number ,C" State Transportbr i Ib[Reserved j <br /> o .SAFETY-KL.EEN SYSTEMS, INC SCR00007150 <br /> D Transporter s phone <br /> CP 7. Transporter 2 Company Name <br /> 8. US EPA ID Number <br /> QE State Trohsporket s ID Reserved f <br /> Transporter's'Phone <br /> 7t �tY Faf� °n, „y tom^ 10. US EPA ID Number <br /> INC G. Sta6000 L-38TH STREET <br /> Z 84 <br /> r SACRAMENTO CA ?5603 �� �-; <br /> a. �.A'00Y�.itOg.J0451 7 H. Facility's Phone <br /> 916 396-4913 <br /> 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12• Containers 13. Total 14. Unit <br /> Z a No. <br /> 2 V',-3 D r�I_.r s�tl°-I.I,N f;f� .i ;rtt 4 T3L' f ry TY e Quantity Wt/Vol I. Waste Number <br /> t— a. f�I. f.1. 1B €al. F vs State <br /> 3 G i.. 1�.I sa t is ' . 34 <br /> 0R U6I:::PA RECl.1L d TCDD a � <br /> 'aCk i�d= : =c4i " ► ahfI aOl.d�T TCf#I3. :3G9.1 <br /> N b. ` EPA/Okher <br /> 00 <br /> as E State 1 <br /> R <br /> oT C. EPA/Other <br /> R State <br /> Uj d EPA/Other <br /> V State' ! <br /> fPA/Other <br /> 1. Additional Deseri tions for Materials Listed Above <br /> p <br /> IC,Hand[SngCodes for Wastes Listed,Above <br /> s <br /> b- <br /> Z c. d. j <br /> f fPC4a1fl Tlnsf�pap§" nd nal no ofi n q <br /> 60 <br /> Z SK 3 HOR 1 ZE0 TO RETAIN L ICE NSED SUB E GUENT CARRIER, AS NECESSARY, <br /> 4r <br /> A 941 _B C D <br /> Q16. 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, acked <br /> J marked,and labeled,and are in all respects in proper condition for transport by highway accordingto applicable pplicable international and national government regulations. p <br /> :e If I am alar a uanti <br /> L 9 q ty generator,I certify that I have a program in place to reduce the volume d toxicity of waste generated to the degree I hove determined to be economical)y <br /> practicable and that I have selected the ll quantic le method of treatment,storage,or disposal rre fly available to m �ich minimizes the present and future threat to human health <br /> and the environment; of I if I am a small quantity generator,I have made a good faith efF to nimize my wggtg gen ration and select the best waste management method that is <br /> available to me and that I can rd. <br /> Printed/T ed N me <br /> I Signature <br /> r Month Day Year <br /> j <br /> T17..17. Trans orter 1 Acknowled ement of Recei t of ials <br /> 4 <br /> N Print d/T Ped Name f <br /> t r, 1 Month<on Da <br /> P �.•� ,; -!C.n Y _. .Year <br /> t B 18. Trans orter 2 Acknowled ement of Receipt of Materials ` r `y l / -7 I tr j <br /> r Printed/Typed Name <br /> E Signature <br /> R s Month Day Year L <br /> F 19. Discrepancy Indication Space <br /> A <br /> C f <br /> II 20. Facili Owner or Operator Certification of cecei t of hazardous materia overed b t manifest e e as t <br /> T c <br /> ted/Typed Name to l <br /> In 1: <br /> Y Sig lure <br /> Loll _ (ylonth Day Year <br /> O NOT W71 BEL THIS LINE. <br /> SC 8022A(1/99) I <br /> Yelll TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 4 8700-22 (Generators who submit hazardous waste for transport out-of-state, 1 <br /> produce completed copy of this copy and send to DTSC within 30 days,) <br />