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State of California—Environmeri Protection Agency <br />Form Approved OMB No. 2050-0039.tExpires 9-30.99) See Instructions on back of L 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on elip (12-pil T-1 8 5 — 0 1 Sacramento, California <br />O <br />n <br />CV <br />V) <br />co <br />INc <br />1i Q <br />V <br />Q <br />Z <br />LEV <br />0 <br />Qc <br />Q <br />Z <br />0 <br />a <br />Z <br />LU <br />t— <br />Q <br />V <br />Cs - <br />un <br />ad0 <br />V <br />Z <br />w <br />2 <br />LLJw <br />0 <br />w <br />ti Q <br />V <br />KA <br />DO—W WRITE BELOW THIS LINE. <br />PRI A)0002177895 B)0002177896 <br />B�fl/PbJ0000457880-8 B )0000457 881-8 <br />DrNDS THIS COPY TO OTSC WI?HIN 30 DAYS. <br />*1�67lax 3000, Sacramento, CA 95812 <br />EPA 8700-22 <br />�, _ —^.r� <br />Generator's US EPA ID No. <br />Manifest Document No. 2. Page I Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal low. <br />I I <br />WASTE MANIFEST CA 0 0 6 47Vi <br />I of 1 <br />1-1 <br />3. Generator's Name and Mailing Address C OS TC O <br />A. State Manifest Document Number 22964146 <br />3250 W GRANTLINE RD <br />B. State Generator's ID <br />y C A 95 377 <br />TQR�CrBtor's <br />Phone ( ) <br />830-5 343 <br />I <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />SAFETY—KLEEN SYSTEMS, INC R?OP9599 <br />D. Transporter's Phone <br />7. Transporter 2 Company Name B. US EPA ID Number <br />E. State Transporter', ID [Reserve . 669 5?40 <br />/ !' ~— <br />YName <br />F. Transporter's Phon t <br />9. Designated Facility and Site Address 10. US EPA :D Number <br />G. State Facility's ID <br />000658 <br />K D 93 4 0 <br />SAFETY—KLEEN SYSTEMS, INC. <br />H. Facility's Phone <br />3700 LAGRANGE ROAD YD 5 4 <br />1 8 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />_ <br />I Containers <br />No <br />o I Type <br />13. Total <br />Quantity <br />. <br />I dUnit <br />Wt/Vol I. Waste Number <br />a, <br />State <br />WASTE FLAMMABLE L1,QUIDS, N. 0. S. <br />G <br />( GASOLINE ) 3 UN1993 P',G II ( ERG#128) <br />D <br />P EPA/Other <br />0 <br />no <br />Eb. <br />Slate <br />N <br />WASTE SOLIDS CONTAINING FLAMMABLE352 <br />R <br />LIQUID, N. 0. S. GASOLINE, BENZENE) 4. <br />1 <br />D <br />p EPA/other <br />T <br />a. <br />State <br />r <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />I <br />i <br />J. Additionol Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a <br />614 / <br />IA) D018 IB) D018� <br />14 c <br />Ic <br />`- <br />I <br />15. Special Handling Instructions and Additional Information <br />MFST <br />R/T#104320523 0002-8617-22 <br />EMERGENCY RESP 800-468-1760(24 HR). IF <br />UNDELIVERABLE RETURN TO GENERATOR. <br />SK CORP AUTHORIZED TO RETAIN LICENSED <br />SUBSEQUENT CARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the con en s o f is c of are u y an ac<ura sly descri e a ave y proper shipp.ng name and are ciossified, packed, <br />and labeled, and are in all respects in proper condition for transport by highwoy according to applicable international and national government reg.tlations. <br />marked, <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 econcr ical)y <br />practicable and that I have selected the practicable method o treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <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 />Primed/Typed Name Signature <br />Month Day Year <br />T <br />Transport 1 Ackrowfedgerri of Receipt of Materials <br />R <br />p <br />S <br />Printed/Type ane <br />nr Si azure <br />Mont Dayj/�� Y <br />' <br />P <br />0 <br />18. Trans otter 2 Acknowled em nt of Receipt of Materials <br />R <br />T <br />PrmName Signature <br />Month Day Year <br />E <br />r � /(� v <br />��, <br />19. 4IDiscrepancy Indication Space ' <br />F <br />A <br />C <br />I <br />` <br />20.- Faci ty eti er c Certific ho of re t of razor <br />ous materials co✓eled b th s man esiebt as cited in 11fri- 19 co_ <br />T <br />P y ed �� <br />Sig urs <br />- M h ay r <br />Y <br />DO—W WRITE BELOW THIS LINE. <br />PRI A)0002177895 B)0002177896 <br />B�fl/PbJ0000457880-8 B )0000457 881-8 <br />DrNDS THIS COPY TO OTSC WI?HIN 30 DAYS. <br />*1�67lax 3000, Sacramento, CA 95812 <br />EPA 8700-22 <br />�, _ —^.r� <br />