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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-W39 (Expires 9.30-99) <br />Please print or type. form designed. for use on elite f 12•pikh) y writer. <br />O <br />on <br />on <br />n <br />N <br />W) <br />co <br />6 <br />O <br />M J <br />V <br />�Z <br />Z <br />3 <br />W <br />W <br />I— <br />Z <br />V <br />W <br />N <br />Z <br />0 <br />V) <br />W <br />Q <br />Z <br />0 <br />a <br />Z <br />W <br />t— <br />J <br />Q <br />V <br />cr <br />0 <br />r <br />V <br />Z <br />W <br />(7 <br />Uj <br />W <br />1 <br />,s. <br />0 <br />W <br />N <br />4 <br />V <br />tri <br />See Instructions on back of pag Department of Toxic Substances Control <br />Sacramento, California <br />DO NOT WRITE BELOW THIS LII E'er <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 8022A (1/99) To: P.O. Box 3000, Sacramento, CA 95812 <br />EPA 8700-22 <br />I. beneralars USME ID No. Manifest Document No. 2, Pogo 1 Information in the shaded.areos <br />UNIFORM HAZARDOUS i, not required by Federal law. <br />WASTE MANIFEST D $2 4 25 all <br />3. Generator's Name and Mailing Address SEARS A/C 6791 A. State Manifest Document Number 23023736 <br />110 PACIFIC AVE <br />TOCKTON CA 95207-5350 B. state Generator's l0 <br />4. Generator's Phone f 09 477-8111 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter s ID (Rase .) <br />AFETY-KLEEN SYSTEMS, INC X 0 0 09 O <br />D. Transporter'sPhone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />. E. State Transporter', ID Reserved.j <br />F. Transporter: s Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State FaciliVs 10 <br />000760 <br />0 8 S 7 <br />AFETY-KLEEN SYSTEMS, INC. <br />H. Facility's Phone <br />000 88TH STREET A 00 0 45 7 <br />SACRAMEHTO CA 95028 <br />916 3 6-4913 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Tocol <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />_.. <br />No, <br />I Tye <br />I` <br />State <br />NON RCRA HAZARDOUS WASTE LIQUID <br />343 <br />ETHYLENE GLYCOL SOLUTION ( LESS THAN 50%)EPA/Other <br />G <br />CA -342,343 <br />E <br />b <br />State <br />N <br />E <br />EPA/Other <br />R <br />A <br />State <br />T <br />c <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />- J. Additional Descriptions For Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />a. b. <br />A) 342 <br />l4 <br />C. <br />d.. _. <br />15. Special Handling Instructions and Additional Information <br />MFST R/T#104772276 0000-3704-30 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />K CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name an are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations. <br />If I am o large quantigenerator, I certify that I have a proram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicalI <br />disposal to minimizes the and Future threat to humon health <br />practicable and that I have selected the practicable method of treatment, storage, or currently available me which present <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 is <br />available to me and that I can afford. <br />Printed/Typed Nam <br />Sign to <br />Month Day Year <br />lem-TQN.a <br />r? i 3 , a <br />T <br />17. Transporter 1 ceipt of Materials <br />APrinted <br />Name <br />Signature <br />Month Day Yer <br />S <br />f• 1,31 014 <br />P <br />8 <br />18. irons rter 2 Acknowle emenF of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />20. Facilityor Operator Certification of ei t of hazardous materials covered b this manifest exce t as n in Item 19. <br />T <br />Printed/Ty a <br />Signature <br />Month Day Y��eor <br />Y <br />'(�j✓""1 <br />.....+�1 <br />L V <br />DO NOT WRITE BELOW THIS LII E'er <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 8022A (1/99) To: P.O. Box 3000, Sacramento, CA 95812 <br />EPA 8700-22 <br />