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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-991 <br />Please prinPSr type. i designed for use on elite (12 pitc. <br />0 <br />sA <br />W) <br />N <br />C`l <br />sr's <br />0? <br />0 <br />0 <br />CP <br />M J <br />00 U <br />® Q <br />CV z <br />CD <br />0 <br />Cn <br />U <br />Z <br />S <br />r � <br />G <br />CN <br />0 <br />cc <br />cc <br />d <br />c <br />c <br />cc <br />a <br />Z <br />C <br />a <br />LL <br />a <br />< <br />E <br />See Instructions on back of 1 6. <br />Departmerl of Toxic Substances Control <br />Sacramento, California <br />V DO NOT WRITE BELOW THIS LINE. <br />PRMM DDQtLt$#} B)0002177896 _ NDS TH15 COPY TO DTSC WITHIN 30 DAYS. <br />DT�'8E2i0l <br />B)0000457881-8 Ta_ P.p. x 3000, Sacramento, CA 95812 <br />EPA 8700-22 <br />I 1 Generator's US EPA ID No Manifest Document No. <br />2, Page IInformotton <br />in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal low. <br />WASTE MANIFEST 6 9 7 <br />of 1 <br />3. Generator's Name and Mailing Address C O S TC O <br />$fate Manifest Document Number <br />3250 W GRANTLINE RD <br />. <br />23020831 <br />B. State Generator's ID <br />TRACY CA 95377 <br />A . Generator's Phone ( 2 0 91 830-5343 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />SAFETY—KLEEN/,SYSTEMS, INC IT R 9OQ5p 3 <br />D Transporter', Phone <br />669 <br />7, Transporter 2 Company f4cri 8. US EPA ID Number <br />E. State Transpa ter', ID IReserved. <br />G <br />F. Transporter', Phone 5%.0 D <br />O <br />9 Designated Facility Nome and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />000658 <br />1 K O531318 08 <br />INC. <br />" Fa[ility',Phane <br />3700TLAGRANGESROADMS, <br />K D053 480 <br />SMITHFIELD <br />1 <br />5-2453 <br />12. Contairers <br />3. Total 14. Un:t <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />No. <br />Type <br />Quantity Wr/Vol I. Waste Number <br />a <br />State <br />W <br />- <br />EPA/Other <br />G <br />E <br />b <br />state <br />N <br />WASTE SOLIDS CONTAINING FLAMMABLE352 <br />R <br />LIQUID, N. O. S. ( GASOLINE, BENZENE) 4.1 <br />DM <br />P EPA/Other <br />A <br />; state <br />T <br />[ <br />O <br />EPA/Other <br />R <br />d. <br />state <br />I <br />I <br />EPA/Other <br />J. Additional Descrip i ns for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed A v <br />a <br />b. <br />_ I B ) D 018 I� }—E►6 �-8 <br />_ <br />1 <br />�0 <br />15. Special Handling Instructions and AddironalInformation MFST <br />R/T#104471873 0002-8617-22 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE <br />RETURN TO GENERATOR. <br />SK CORP AUTHORIZED TO RETAIN LICENSED SUBSEQUENT <br />CARRIERS AS ECESSARY. <br />SKDOT# <br />B: 34273 D: <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the -contents of this consignment are fully and accurate)y described above by proper shipping name and are classified, pocked, <br />highway International and national regulations. <br />mark6il, and labeled, and are in all respects in proper condition for transport by according <br />to applicable government <br />j IFI am a large quontiy generator, I certify that I have o program in place to reduce the volume and <br />disposal <br />toxicity of waste generated to the degree I hove determined to be economically <br />to me which minimizes the present and future threat to humor health <br />practicable and that I have selected the Practicable method of treatment, storage, or currently <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize <br />ovafloble <br />my waste generation and select the best waste management method that a <br />available to me and that I can afford. <br />Printed/T d Name <br />Signature <br />Month Day Year <br />K <br />T <br />17. Tr s orter 1 4knowledgement of Receipt of Materials <br />R <br />P( ed/Typed e <br />(Signature <br />Mont ]py Yea <br />P <br />B <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />TPrinted/Typed <br />Name Signature <br />Month Day Year <br />A <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />20. FacilityOwner or O er CertiFcalion of receiar of hazardous materials covered b anif I exce t as noted in Item 19. <br />I <br />T <br />Printed/Typed Name Signature <br />::]Month Day Year <br />Y <br />V DO NOT WRITE BELOW THIS LINE. <br />PRMM DDQtLt$#} B)0002177896 _ NDS TH15 COPY TO DTSC WITHIN 30 DAYS. <br />DT�'8E2i0l <br />B)0000457881-8 Ta_ P.p. x 3000, Sacramento, CA 95812 <br />EPA 8700-22 <br />