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State of California—Environmental Protection Agency ®185-01 <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions Ofl bQCIC O 8 6. Department of Toxic Substances Control' <br /> Please print or type. Form designed for use on elite(12-pitch 161iter. Sacramento,California <br /> 1. Generator's US EPA ID No. M6niFest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS 74 4 1 3 442 is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address INTERLAKE A. State Manifest Document Number <br /> 1029 E SACRAMENTO <br /> B, State Generator's 1D t <br /> L OD Irator's Phone( �) CA 95240-4799 <br /> 20 333-3500 r <br /> N 5. Transporter 1 Company Name ' 6. US EPA ID Number C. State Transporter'sID Reserved I <br /> h 0eq <br /> 0 <br /> SAFETY—KLEEN SYSTEMS, INC R 0 T <br /> 0 MJ D. Transporter'sPhone - <br /> p oD 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's•ID(Reserved.] . <br /> F: Transporter's Phone <br /> 9. Desi noted Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 'tea SAF TY-KLEEN SYSTEMS, INC <br /> Z 5050 SAL I DA BLVD <br /> 0 SALIDAF CA 95368 CAT 000613968 H. Facility's Phone <br /> "%� 209 545 1011 <br /> .�a 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> �^� �V No. Type Quantity Wt/Vol I. Waste Number <br /> '"eZ a. State <br /> F WASTE C014BVSTIBLE LIQUID, N. O. S. DM G <br /> (PETROL. PHT ) NA1993 PGIII RC11 � EPA�Otfae <br /> 3 G (DOO 1)ER 128 (6. 7#/ ) (DO 18. DO39, DO4O) <br /> N. N b. - State <br /> O <br /> 00 <br /> 00 E <br /> ve <br /> R EPA/C)tltr <br /> v 04 <br /> AC. <br /> State' <br /> 0T <br /> a0'o O <br /> he <br /> R _ SPA/Cttr <br /> Z d. <br /> are <br /> Lu EPAC)fFteK <br /> V <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> I (A) D018 D039 CA) D040 a. 14 b. <br /> LG <br /> Q <br /> Z 442 000241 Z-317 09'. <br /> 15. Special Handling Instructions and Additional Information0045 09974091 0004632 <br /> P EMERGENCY RESP#800-468-1760: 34HR <br /> a <br /> Z <br /> Uj <br /> A 801 B C D <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shippping name and are classified,packed, <br /> Q marked,and labeled;and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> V <br /> If I am a large quantiy <br /> generator,I certiff 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 /> 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 1 am a small quantity generator,1 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O <br /> Printed/Typed NameSigr 4lure � �' jj� Month ay Year <br /> Z '` 1 <br /> Lu T 17• Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> w p Printed/ yped Name ,p Signet onf T11 ® a Yea <br /> LU S P. V M f y , <br /> U_ - 01 <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O R Printed/T ed Name Si nature Month Day Year, <br /> w E <br /> T Printed/Typed 9 <br /> rn R <br /> V 19. Discrepancy Indication,Space <br /> Z F <br /> A <br /> C <br /> L <br /> F 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by thilrry6nifest except as 6oted in Item 1 <br /> T I &)/a <br /> Printe fT Name Signature ron2 Da Year• 1 <br /> 0 r� � <br /> 1h /Z <br /> DO NOT WRITE BELOW THIS 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 />