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State of California--Health and Welfare Agencyr ^ Department of Health Services <br /> -,FFed OMq No.2050-0039(Expires 9.30-91) R L 1 ; F Toxic Substances Control Division <br /> Please print ar type. (Form designed for use on elite(f2- writeq. Sacramento.California <br /> I UNIFORM HAZARDOUS 1, GIMWII US EPA ID No. o pNo Information in the shaded areas <br /> WASTE MANIFEST ClAl0 (11 ^ 11 ? z r ( ) of isnot required by Federal few. <br /> r 3. Generator's Name and Mailing Address A. Stele Manifest Document Number <br /> AJCO DELTA 8-9511 <br /> 705 N CARLTON AVE. , STOCKTON, CA 95203 e. stale Generators I <br /> 4. Generator's Phone(20 9) — 1 01 Z r f� <br /> 5. Transporter t Company Name e. US EPA ID Number C. Slate Trenaponer'a ID <br /> a CiI17,141 C,nl Ir n i F inirr-P r'1 C -101 I'll 11 91 Pi ril 71 11 r D. Transporter's Phone - <br /> 10 7. Transporter 2 Company Name 9. US EPA ID Number E. Stele Transponer's ID <br /> CP <br /> p F. Transporter's Phone <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA 10 Number O. Stale Fa<ilily'a ID <br /> CHEFIICAL WASTE MANAGE!IENT <br /> C I Al TI 01 011bL(aLyL6' 11 11 71 <br /> 35251 OLD SKYLINE ROAD H. Facility's Phone <br /> < KETTLEIIAII CITY, CA 93239 C R TiC f 6 r T (209) 386-9711 <br /> Z <br /> 12. Containers 13. Total 14. 1. <br /> I0 I1. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> `v '/ jWASTE FLAMBLE LIQUID, N.O.S. FLAIIAGLE s'°'° 1!'1 <br /> lz G l LIQUID UN1993 (FOO5 EPA/Other <br /> i N I 111615 G FOOS <br /> N ° HAZARDOUS WASTE SOLID, N.O.S. ORN—E, NA 9139 slate 513 <br /> S T (EI4PTY CRUSHED CONTAINERS LESS THAN 30 GAL 2 5 y EPAfa�{n <br /> a R C. Slate <br /> g <br /> m <br /> EPA/Other <br /> W d. SIe1e <br /> Z <br /> W <br /> O EPA/Other <br /> W <br /> Z J.Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 0a. b. <br /> A) PROFILE P,E§2623SFO .. -- 03 <br /> Ju 3) PP.OFILE $G16634SP0 - C. d. <br /> J <br /> Q <br /> Z ' <br /> O <br /> r IS. Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> H <br /> J <br /> (a7 I8. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J <br /> and are classified.packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> Nnational government regulations. <br /> tY 11 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 <br /> O to be economically practicable and that have selected the practicable method of treatment.storage,or disposal currently available to me which minimizes the <br /> Y present and future threat to human health and the environment;OR,it I am a small quantity generator,1 have made a good faith effort to minimize my waste <br /> O generation and select the best wsate management method that is available to me and that I can afford. <br /> Z <br /> Printed/Typed Name Sip e I v) 7 Month Day Yee, <br /> W AI-Ail T. F:STES •B, �4 <br /> wT 17. Transporter 1 Acknowledgement o1 Receipt of Materials _ <br /> 2 R <br /> < A Printe0/Typetl Neme Signature Month Day Year <br /> S �(^ y'i 71 <br /> W O 18. Transporter 2 Acknowledgement o1 Receipt of Materials <br /> < R Printed/Typed Name Signature Month Day Year <br /> 0 E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A .. .. <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Nam, Signalu�✓ _ /1 // Month Day Year <br /> OHS 8022 A(I 188) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> Yellow:TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />