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StatAri <br /> California-Environmental Protection Agency <br /> Forapr6eed OMB No.2050-0039(Expires 9-30-99) - - } See Instructions on back of 9e 6. Department of Toxic Substances Control <br /> PI" r tyke. Form designed for use on elite(12-pitch riter. Sacramento,California <br /> 1. venerator's US EPA ID No. aM fest D cument No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS C jr D07 46 4 2 30 1 � � � _ � is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Ge Brat s Aft, z A. State Manifest Document Number ' <br /> 1.O Z <br /> L ODS I CA 95240-4799 B. State Generator's tD <br /> LO 4. Generator's Phone (2 0 9 ) 9 3 3 3 5 0 0 <br /> n <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Trinsparters--ILO <br /> D Reserved] <br /> o SAFETY--KLEEN SYSTEMS, INC SCR000075150 R. Tr6loortersPhone <br /> , 0',O 6 7, <br /> 7. Transporter 2 Company Nome 8. US EPA ID Number 'EState TrasporYer's IDI eserved.f ' <br /> QF Transporter's'Phone <br /> 9. Designated Facility Name and Site Address r• 10. US EPA ID Number `G. Stat <br /> 0 g g ryq Cyg SYSTEMS, <br /> sg y+ 00fir°#60 O0 17 <br /> am <br /> ,j6000 88TH STREET 't.A.0000084J.yt7.° H. Facility's Phone <br /> � O -SACRAMENTO cibr 9582 , 916 386-4913 <br /> 12. Containers 13. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> V No. Type Quantity Wt/Vol L Waste Number <br /> Z ° !$.ED CLEARING COMPOUNDS, State 134 <br /> F L (,,) SID ( NOT USDOT OR USEPA REGULATED) DM G <br /> G AQUEOUS PARTS WASHER -SOLUTION ( 8. 3 GAL ) PFAfCttftar <br /> O N b. $tats <br /> m E <br /> v R EPA�C�tTYer; <br /> ``'v A C ware, <br /> o T <br /> 000 0 <br /> R EPAIOther <br /> w d. State <br /> Z <br /> w <br /> V EPAfOther <br /> w <br /> !^ 1 Additional:Descriptions for Materials Listed Above K. Handling-Codes for Wastes Listed A6ave'- <br /> LU <br /> ce <br /> C. d; <br /> Q <br /> Q Ins nd na Rat. N . C <br /> �CER-A-B-LERETURN TO GENERATOR.ElRATOR. <br /> " ORP AUTHORIZED ,TOET I : LIENSED SUBSEQUENT ueL41i79s+CSCRt . <br /> Z <br /> LUSKDOT4 A: 941 C: D: <br /> t- <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 quantiy generator,I certify that I have a program in place to reduce the volume and tonicity of waste generated to the degree I have determined to be economically <br /> °- practicable and that I have selected the practicable method of treatment,storage,or disposal rently 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 mode a good faith e .minimize my waste geration and select the best waste management method that is <br /> oc available to me and that 1 can afford. ✓ <br /> O / <br /> } Printed/T ed N me s% Signature Month Day Year <br /> Z A�dF ! ,•r"7e�P..,✓V1, �. ro'. .�+' ";1 ,>!� !f t.+� d'- <br /> w R 17. Transporter 1 Acknowled ement of Receipt of MgArials 4 <br /> LU <br /> A Printe /Ty ed Name Signature Montfj, Day Ysar, <br /> R <br /> �, P fn <br /> U_ 0 18. Transporter 2 Acknowled ement of Receipt of Materials <br /> 0 T Printed/Typed Nome Signature Month Day Year <br /> w E <br /> cn R <br /> Q <br /> V F 19. Discrepancy Indication Space <br /> Z A <br /> C <br /> L <br /> 20. facility Owner or Operator Certification of rec i t of hazardous materials'Xverqcl by thi-s"Acnifes nce s no in Ilem 19. <br /> T i ited/ ped Name S 6nature ,,, Mont ay Year <br /> L& I \kAl � Y--,. 'tPo <br /> DO NO WRITE SEL "k LI . <br /> ellow: TSDF SENDS T� )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 />