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State of Califovpio—Environmental Protection Agency <br />Form ApprovedbMB No. -2050-0039 (Expires 9-30-99) See 111 !ructions on back of 8 6. Department of Toxic Substances Control <br />Ple*e print or type. Form designed`for use on"efite 112 -pitch) ter. ;, Sacramento, California <br />177 <br />�0 <br />1. nerator's US EPA ID No. Manifest Document N <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />s <br />,r <br />isnot required by Federal low. <br />15. Special Handling Instructions and Additional Information <br />WASTE MANIFESTA <br />() 2 Aof <br />MF'ST ii/ 1O361CIO5s30002-8013-01 <br />Z.EMERGENCY <br />RESP 800-468-1760(24FILL) IF` €1�dOSL.T ERABLE RETURN TO GENERATOR. <br />3. Generator's Name and Mailing Address <br />A. State Manifest Docume4?,Number <br />4 <br />SK. -COR - RUTH RIZE-D TO-EiETAT-N- LaICENSE=LDS€BESEQUE-NT ARRIERS AS NECESSARY. <br />MARTIN BROWER <br />4704 F°ITE T.22324218 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the conteAK001ritgn rAare fullyc rat described above by pro •en shipping name and ar rossified, packed, <br />' <br />B EState Generators ID <br />0 <br />, <br />r <br />I <br />CA95200 <br />-�� <br />N <br />5. Transporter 1 Compan- e ? Q, 6. US EP;A`ID Number - - <br />C.-StateTrarrsporter's"IC3[Reservedjl <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to ' inimize' my waste generation and select the best waste management method that is <br />goo <br />LO <br />ao <br />Oavailable <br />,.r <br />s <br />I <br />D -Transporter s Phone <br />CD <br />Printed/TypedName <br />SAFETY—KL�E.EI�t SYSTEMS INC. T . {3 O O� � <br />r> <br />L <br />1 <br />00 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. ,State Transporter's ID [Rase 669-5840 <br />�eQ <br />- <br />F. Tronsporter's`Phone <br />dU <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G."State Facility's ID <br />r .' <br />Printed/Typed Name <br />C1t <br />, <br />U.1 <br />S <br />F <br />jZ <br />05014 <br />p <br />vi1 d <br />18. Transporter 2 Acknoemenf o .Recei t of Materials <br />H.Facrhty's Phone ` <br />R <br />T <br />CL,EAN ` HAR ORS SAN JOSE LL _� <br />Si nature <br />$ <br />�O <br />21 <br />OU <br />E <br />R <br />Q <br />V <br />�Q <br />aV <br />DOT SAW Dcreiption (ncludingProperShipping Name, Hazard Class, and ID NuOmbe st <br />11 <br />T2 Containers <br />13. Total <br />AQuantity <br />nit <br />Wt/Vol <br />1. Waste Number <br />C <br />No. <br />Type <br />Z <br />l <br />a, <br />l <br />20. Facili Owner or O erator Certification of receipt of hazardous materials covered by this,,Mcmifest except as noted in Item 19. <br />State <br />T <br />Printed/Typed•Name <br />inti —R RA HAZARDOUS WASTE LIQUID <br />_ <br />Month Day Year <br />M, <br />KZ <br />EPA/Othe <br />G <br />OIL, WATER, SLUD(;E(._ QT POT REGULATEa,).,- <br />DISC 8022A (]./99) (Generators who submit hazardous waste for transport out-of-state, <br />�t <br />- <br />� <br />N <br />a <br />- <br />;:N <br />b• ,,. . , <br />State - <br />;I <br />Zo <br />R <br />EPA/Other <br />N <br />' <br />�t <br />,A <br />C. <br />state <br />R" <br />s <br />EPA/Other <br />T <br />t <br />W <br />d <br />State <br />.l <br />EPA/Other' <br />;t <br />Cie <br />177 <br />f <br />c <br />d' <br />s <br />,r <br />O <br />15. Special Handling Instructions and Additional Information <br />t— <br />MF'ST ii/ 1O361CIO5s30002-8013-01 <br />Z.EMERGENCY <br />RESP 800-468-1760(24FILL) IF` €1�dOSL.T ERABLE RETURN TO GENERATOR. <br />w <br />SK. -COR - RUTH RIZE-D TO-EiETAT-N- LaICENSE=LDS€BESEQUE-NT ARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the conteAK001ritgn rAare fullyc rat described above by pro •en shipping name and ar rossified, packed, <br />Umarked, <br />and labeled, and are in all respects in proper condition for transport by highway according to appcable international and national governmentregulations. <br />-�� <br />if I am a large quantiy generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economical)y <br />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 />N <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to ' inimize' my waste generation and select the best waste management method that is <br />goo <br />Oavailable <br />to me and that I can afford. <br />I <br />Printed/TypedName <br />Sinatu' e <br />r> <br />L <br />Month Day Year <br />v9a. G <br />F6 <br />T <br />17. Transporter T Ac mowled ement of Recei t of MotqAals <br />R <br />A <br />r .' <br />Printed/Typed Name <br />Signature ,r _, r. ;} onth Day Year. <br />U.1 <br />S <br />F <br />mow• <br />u.. <br />p <br />vi1 d <br />18. Transporter 2 Acknoemenf o .Recei t of Materials <br />R <br />T <br />Printed/T ed Name <br />yp <br />Si nature <br />$ <br />Month Da Year <br />M Y <br />LU <br />tq <br />E <br />R <br />Q <br />V <br />19. Discrepancy Indication Space <br />Z <br />F <br />q <br />C <br />l <br />l <br />20. Facili Owner or O erator Certification of receipt of hazardous materials covered by this,,Mcmifest except as noted in Item 19. <br />T <br />Printed/Typed•Name <br />Signature _ :'Cr <br />_ <br />Month Day Year <br />KZ <br />DO NOT WRITE BELOW "THIS LINE. <br />Yellow; TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DISC 8022A (]./99) (Generators who submit hazardous waste for transport out-of-state, <br />produce completed copy of, this copy and send to DTSC within 30 days) <br />EPA 8700-22 <br />