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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99j See Instructions on ba page b. Department of Toxic Substance: <br />Please print or type, Form designed for use on elite (I2�ypewriter. i Sacramento, Colifornic <br />C <br />Lt <br />K <br />r <br />c <br />v <br />a <br />C <br />C <br />a <br />M-4 <br />L0C <br />Nq <br />N k - <br />Z <br />? X <br />3 <br />CN <br />C <br />cca <br />CS <br />c <br />C <br />a <br />ck <br />LL <br />r <br />Z <br />LL <br />l: <br />LL <br />V1 <br />Z <br />LL <br />De <br />a <br />z <br />C <br />a <br />Z <br />W <br />x <br />a <br />U <br />J <br />IL <br />Ln <br />Ix <br />O <br />} <br />U <br />Z <br />LU <br />0 <br />cY <br />Let <br />W <br />U- <br />0 O <br />w <br />N <br />. Q <br />U <br />c <br />J DO NOT WRITE. BELOW TAd LINE. ' '` <br />0 <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />C AL `tidS ? 643; <br />of <br />R �L sE <br />3. Generator's Name and Mailing Address MAR s. ,� �'•L �•ri.• �r_F� <br />A. State Manifest Document Number <br />2251905 <br />4704F ITE CT <br />r f.00K1014 CA '82'05 <br />B.- State.Generator'sID <br />A. Generator's Phone ( 209 946-374e <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. State Transporter's 1D (Reserved.), ; <br />"SAFE f Yr-ALEEN BBS s EMS', INC °TXR,00O0 Cr 50? 93 } <br />D: Tronsporter's Phone' <br />1669-574Q <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Trcrospofte6 101Reserveda , it <br />f.. Transporter's Phone <br />C° De fgn ted. Facility qm and Site -Ares V ' '� Wr 10. US EPA ID Number <br />G: 'State Facility's 1D_ r <br />50 50 SALIDA BLVD <br />.._ <br />H. Focility's'ehone <br />SAL I DA CA9 5368 • .A 6"0006 1 :, 968 <br />X09, ! 5--101 I <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number( <br />- <br />12. Containers <br />13, Total <br />QuantityttWt/Vol <br />14. Unit <br />I-..N/aste: Num�bger. <br />No. <br />�� 1• �• h��••� 4�^th,q�yf pi 5r��k <br />a. M1..',:. ED CL ::.f'�i� I t ai. CS.A7�57" G.41J1'� D s �s O: T <br />r� 2 r-,.B. N1. <br />USED <br />DM <br />DM <br />Q <br />State 134 <br />. <br />LIQUID (NOT 1JSDOT OR US"EPA -REQ- W�: a ��}� <br />` <br />EPA/Other <br />G <br />AG-UEOU s PARTS WA ai4ER SOLUTION � 13. 3#GAL ) <br />E <br />N <br />E <br />_ _ <br />b. - <br />�¢ THE IMAGE DISPLAYED S �1 <br />State <br />:EPA/Other <br />A <br />NOT AS LEGIBLE AS THIS j <br />State <br />IT IS LIKED' DUE , <br />T <br />OVERLAY, <br />POOR QUALITY OF THE <br />EPA/Other <br />lier <br />R� <br />R <br />TO THE <br />DOCUMENTS/IMAGE j <br />ORIGINAL <br />d. __ _-- <br />State <br />EPA/Other <br />i <br />J. Additional Descriptions for Materfals listed Above <br />K. Handling Codes For Wastes <br />listed Above <br />6.. <br />C., <br />d. <br />0lNing nstr, o Fdia�nfooion .+wt�:/ cLbL ? ; <br />]5 ►s e.x; r 1L2`3,' Q , <br />- 760 24HR <br />941 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 shipping name and are classified, packed, <br />marked, 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 progrom in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical] <br />practicable and that 1 hove selected the practicable method of treatment, storage, or disposal currently avoiloble to me which minimizes the present and Future threat to human heal) <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that <br />available to me and that I can afford. 4 <br />Printed/Type rryt� _ <br />Signature <br />onth Day Y <br />qj <br />17. Transporter l Acknowledgement of Recei t of Materials <br />RT <br />A <br />Printed/Typed Name Sign re Mont Day Y. <br />5 <br />i G a <br />0 <br />18. raps oAer 2' Ac Howledgement of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Y. <br />E <br />R <br />I <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />' <br />f <br />L <br />F <br />20. a 'li Owner or Operator Certification of receipt of hazardous materials c ere b this manifest except as n d in Item 19 <br />T <br />tri ted yped ame <br />� <br />Si otu <br />Day YY <br />740 <br />Q r�' <br />J DO NOT WRITE. BELOW TAd LINE. ' '` <br />0 <br />