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ss1_ SK SHIP# 2-2-6352830 lillll1111111III1I111111RI1111111III 006 .3915916K6 Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1-Generator i4 Number 2.Pa e, of 3. me R e Ph 70666391591 .SKS t Tracking Number UNIFORM MAZARI]QUS L..PD9824P15351 g � � ��—��—j7tB WASTE MANIFEST 6.Generator's Narne End Mailing Address Generator's Site Address(it different than mailing address) Cal—Trans Shop 10-- Lodi Cws 845 E Pine St I-0 D ICA 5a _ CA 95-c-'40-3108 Generator's Phone: p }209-333-6 s.Trfflfft tct '�STEMS I NG U.S.EPA ID Number T n Rftt000812'05 7.Transporter 2 Company Name lt-S.EPA ID Number 8.Designated Facility Name and Site Address SA E T Y—r LE_N OF CALIFORNIA U,$.EPA ID Number 6880 WITH AUE. NEWARK , CA94560510--?95-440 CAD980887` 18 Facility's Phone: o f 9b.U.S.DOT Description(indudirg Proper Shipping Name,Hazard Class,ID Number, IQ.Containers 11.Total 12.Unit 13.Waste Codes H s and Packing Group(if any)) No Type Quantity WIN01. ' NON RCRA HAZARDOUS WASTES 1-T UID TT 133 o ETHYLENE GLYCOL SOLUTION (LESS T 41PI f 50%) a d .� Z 2. W t� 3. 4. I Sp4cial Handling Instructions and Additional Information TSD;UG 77803257 CA47958 201835 CSG-1 24H -468--1760-Cl-€:SK/TF a-Ca-tit ract r otainerl by on initial -oars or,er to add jrSsubstitute ztddi.tional 4ra.ns artC-r-.', .ot) eTiea?o 5. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the coplenis of this consignment are fully and accurately described above by the proper shipping name,arca are classified,packaged, marked and labeledlolacarded,and are in all respects in proper condition for transport according to applicable international and natio4 govemmenlat 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 EPAAcknovrledgment of Consent. I certify that the wwze minimization statement identified in 40 CFR 262.27(a)(if I am a large quarbty generator)or(b)(if I am a sTM quantity generator)is we. Genera r Offerors PrintedlTyped Name Sigriewre Month Day Year –a 16,International Shipments a' i; ❑Import to U - ❑FxpoA twin U.S. Pat of entryte : Transporter signature(for exports only): Date leaving 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 dnledlTyped Name Signature Month gDay Yea; Transporter 2 PrintedlTyped Name Signature Month Day Year 4 1- 1 B.!?lsctepaccy i 8a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ElFuli Rejection Manifest Reference Number 1 rib.Aitemate Facility(or Generator) U.S.EPA ID Nomber a U ru Facility's Phone: y�y Ik Signature of Alternate Facility(or Generator) Month Day Year Q 19.Hazardous Waste Report Management f Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Cn © 1 2. 3, 4• 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinledlTyped Name Signature Month Day Year FP`Ipp 12R&W Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED)