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SSl_ SK SHIM# 68 5 96 Please print or type. Form Approved.OMB No.2050-0039 1'.Generator ID Number 2.Page 1 of 3. T R s o se Ph 4.Manifest Trackin Number UNIFORM HAZARDOUSCAL � 34 a�7- 1� T(rf .I"M , WASTE MANIFEST SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) IRDESA - Golden Bate AD SA - Golden Gate 18501 West Stamford Rd Attn Samuel MchenrY 18501 Stamford Ind TRACY CA 95377 Attn Lester Sato Generator's Phone: ' -5374 TRACY CA 95377-9708 6.Tr [1.GIt SYSTEMS INC U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name-and Site Address SAFE TY"`I LEEN OF CALIFORNIA U.S.EPA ID Number 6660 SMITH AVE. NEWARKv CA 94560CAD980887418 510--795-440 Facility's Phone: I 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. NON RCRA HAZARDOUS WASTES UQUID TT _ S 133 o ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) Z 2. tW7 3. 4. 14,Special Handling Instructions and Additional Information TED d EVO ADRO 198 C9G,S 4H MER65 CY#800-46R--1760-GH/SK/'TFI- Contract retained by generator confers a en'y authori y 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name., ✓ Signature r i }� Month Day Year 3 E' ..j 16.International Shipments F- El Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: LU LU 17.TransporterAcknowiedgment of Receipt of Materials Transporter 1 Printed/Typed NameSignature Month Day Year jf N..... f r Z Transporter 2'Printed/TypedName Signature Month Day Year a t- 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection 0 Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number fs J V U- Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. r 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year t r EPA Form 8700-22(Rev.12 17) Previous editions are obsolete. GENERATOR'S INITIAL COPY 1y€��lli.a��3�