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ate of(^olifornia-Environmental Protection Agency <br /> F rm Ap{'roved OMB No.2050-0039(Expires 9.30-99) rlhstruetions an back of @ b. Department of Toxic Substances Control., <br /> ' se P,int or type. Form designed for use on elite(12-pitchriter. 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 CAD074642 X01 ��J.�*� � is not required by Federal law. <br /> � of <br /> 3. rl rat is Name and Mailin Address at_ a A. State Manifest Document Number. <br /> 102 S SAC A Tr3 <br /> L_ DI CA 95240-4799-a'C�p' B State Generators Ib <br /> A A. Generator's Phone(.209) 333-35000 <br /> ,r <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C 5tateTeaasporter s'tb[Res00 <br /> erved] <br /> SAFETY....KLEEN SYSTEMS, INC SCR000075150 D,' Ttansporter'sPhone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E $tate Trdns <br /> P P Y porter's Ib(Reserve � t <br /> QF. Transporter's Phone <br /> Vu <br /> ity„ ans(,$i e,�f�s 10. US EPA ID Number G. State Facility's ID <br /> f.„. _r '� 4a' d r ?a ?'N!. C 0 O <br /> r� <br /> � ��, � 'f�' f r ;� a �:l -;:1 Jt <br /> .r..% t r, r 3 H. Facility's Phone <br /> 111 0 _.. .. <br /> 916 386--49 <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> 12. Containers 13. Total 14. Unit <br /> V No. Type Quantity Wt/Vol I. Waste Number <br /> Z ° State <br /> g)gk..t)g�i�., <br /> L TGk)11) (NOT U-5DO r OR idaER F"ra” REGUI A"I"I*D) � � f EPA�Other <br /> 3 G A01JEOV,S PARTS WA F•TER SOI—kJT'ION ('a3. 3#GAL) <br /> c*i E b. <br /> p <br /> 00 <br /> 00 Ear <br /> v R <br /> EPAIOtber- <br /> A c <br /> O T State <br /> 00 O <br /> r <br /> R EPA/Othe ' <br /> LU <br /> wd. <br /> t- <br /> V EPAI(>1het: <br /> Addidooal Oescriptiorts.frir fvlat4i'li .listed Above it'Hand tng Oodas far Wastes Listed Aaove` T <br /> o. 6_ w <br /> LU <br /> e.. cl <br /> I H iIn one i ati ^'. r . a. , r.,.1 •,d d 4 <br /> Z ,SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT ARRIE.R, AS NEC,Es-9ARY. <br /> Uj <br /> A 941 13 <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 /> J <br /> J_ <br /> if I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that 1 have selected the practica6le method of treatment,storage,or dispos urrentfy 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, ort o minimize my wastggeneration and select the best waste management method that is <br /> O available to me and that I can afford. <br /> Printed/Typed e � Signature Month Day Year <br /> V <br /> w T 17. Trans orter 1 Acknowled a nt of ecei t of Materi j <br /> LU R ed Name <br /> -7,Print d/ g j __. Month Day Year <br /> LU R p ..-. -. - _.. . Si naluce'T-., _ . <br /> LU SLU P .• /wl faielll <br /> rL0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name Signature Month Day Year <br /> rti E <br /> N R <br /> V1.9. Discrepancy Indication Space -^' <br /> Z F / <br /> A <br /> C i <br /> ( 20. Facili Owner or Operator Certification of receipt of hazardous materials covered6y-this,manifest exce t oa notekl ins Item 19. / <br /> r-isri?ted_/TYped Name f Signature �•� ' <br /> _ Month Day YB <br /> DO NOT WRITf-BROVVITHIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />