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State of California Environmental Protection Agency <br /> f Yorm Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch) ter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> F <br /> UNIFORM <br /> FOUS e„ � ) of� is not required by Federal law. <br /> ASE MANIFEST <br /> 3. Generator's Name and Mailing AddressA. State Manifest Document Number <br /> O �( E" j ( / `A 22964412 <br /> B. State Generator's ID <br /> A. Generator's Phone PSC ` f �°f �(�t� <br /> N 5. Transporter 1 Company Name f J 6. US EPA ID Number V C. State Transporter's ID[Reserved.] <br /> LO <br /> 00 AFETY- MLEEN SYSTEMS INC, D. Transporter's Phone <br /> O j ( <br /> O � } 7 � <br /> S69--5&40 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> .Q <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Faciltys ID <br /> 050702 <br /> ItZVERCREEN COIF. INC one <br /> Facility's Ph <br /> I'0 880 SMITH AVE CAD9$O8t37 1.� H. Facy <br /> f J WA.RK CA 94560 510 795- 4043 <br /> 12. Containers 13. Total 14. Unit <br /> U11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantify Wt/Vol I. Waste Number <br /> State <br /> a NON--RCRA HAZARDOUS WASTE LIQUID -p <br /> 3 G OIL, WATER, SLUDGE( NOT DOT REGULATED) [ <br /> O E 6 Y State T (� t EPA/ d 0 N <br /> oo E EPA/Other <br /> N R - F15 it <br /> 4 A c cj ✓ State <br /> o T �l�n <br /> ao R ,��® EPA/Other <br /> W d. <br /> State <br /> Z EPA/Other <br /> V <br /> N L Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O 1 b. <br /> j <br /> LL! <br /> o_ <br /> C. d. <br /> Q <br /> 0 15. Special Handling Instructions and Additional information MF'ST R/T t?OOOOOOC>O 0-000-00 <br /> a KMERGENCY RESP 800-466-1760( 2 HR). IF UNDELIVERABLE RETURN TO GENERATOR, <br /> Z SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br /> LU <br /> 16. GENERATOR's CERTIFICATION: I hereb declare that the contents of this consignment are full 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 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 /> CL practicable and that I have selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health <br /> rn <br /> and the environment;OR,if I am a sma I quantify generator,I have made a good Faith effort to minimize my waste generation and select the best waste management method that is <br /> Oavailable to me and that 1 can afford. <br /> r ri ed/Syed Name } Signatur' Monih Day Year(, <br /> Z \. i ��14'T�, l f1 �"p 1 <br /> w T 17. Transporter 1 Acknowl d ement of Receipt of b6aterialls <br /> R _ Month ay Year <br /> LU d Printed/Typed Name Signature <br /> Uj <br /> U- 0 18. Transporter 2 Acknowled ement of Recei t of Materials <br /> 0 RT Pr' ted/Typed Name Signature Month Day Year <br /> W <br /> y <br /> 8 :�-:�,�.t vi <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> 1 <br /> I 20m acili Owner or Operator Certification of receipt of hazardous materials-covered b this manifest except as noted in Item 19. <br /> _. t "*., Month Da Year <br /> T 'nted/T eyd Name may' t qct SigaatureN ---,,, Y r <br /> jj <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 22A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 60produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 87022A <br />