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Form Approved OtIB No. 2050-0039 (Expires 9-30-88) 1 Toxic Substances Control Division <br />Please print or type. Form designed for use on elite /2- itch t ewriter . Sacramento, Califgrnis <br />UNIFORM HAZARDOUS191116 Generator's us EP fA No. QI RI Z. Manila 2. Page / Information in the shaded areas <br />Da ument of is not required by Federal law. <br />WASTE ANI T a > <br />3. Generator's Name and Mailing Address A. StateManifest Doc m®tit Nu r ' <br />Santas Co. 8762-!018 <br />Diamond & E. Worth St. B. State Generator' Is O <br />4. GenfiAgeMack, CA 95205 <br />-Sqransporter 1 any Name 6. US EPA ID Number C. State Transporter'a ID <br />6D. Transporter's Phone 1d11 Y <br />7. Tr sorter 2 Company.Nams , a. US EPA: IID Number E.' Stale Transporter'd ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. S cllit 'a ID <br />Chemical W Management, Inc. <br />35251 Old Skyline Blvd. H. Fain7'iTy's Phone <br />Kettleman City, CA 92239 <br />12. Containers 13. Total 14. 1. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) Quantity Unit Waste No. <br />No. Type Wt/Vol <br />G a. WasteOil Contaminated Debris <br />State <br />94 <br />E California Regulated w tto `' y EPA, <br />N , <br />Name <br />E b. State <br />R <br />A EPA/Other <br />T <br />R a State <br />EPA / Other <br />d. State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br />Bunker Oil Contaminated D0jr*p,_. <br />w„ <br />C. d. <br />1§. Speci ndling Instructions and Additional Information <br />Gloves, safety se <br />16. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br />name and are classified, packed, marked,• and labeled, and are in all respects in proper condition for transport by highway according to applicable <br />international and national government regulations. <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 <br />determined to be ecogomically practicable and that I have selected the practicable method of treatment° storage, or disposal currently available to <br />me which minimizes the, present, and future threat to human health and the environment; OR, if) am a small quantity generator, I have made a good <br />faith effort to minimige my waste generation anO select the best waste management ;method that is available to and that I can afford. <br />i <br />Printed/Typed Name/ Signature j Month Day Year <br />7j a <br />T 17. Transporter i' Acknowledgement of Receipt of Materials _ <br />R <br />A r /Type ame Signature Month Day Year <br />N. <br />S <br />PO /8. Transporter 2 Acknowledgement of RiscelipL.Wterials <br />R <br />T Printed/Typed Name Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F _b . <br />A <br />C <br />1 <br />L <br />1 20. Facility Owner or Opera Certification of receipt of hazardous materials covered by th' anifest except as noted in Item 19. <br />Y Printed/Typed Name Signature Month Da Y <br />I <br />DHS 8022 A (1/67) <br />EPA 8700700-22 Yellow: TSDF SENDS THIS COPY TO GENE ATOR WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br />(Rev. 9-86) Previous editions are obsolete. <br />IN CASE OF AN EMERGENCY OR SPILL, CALL THE NATIONAL RESPONSE CENTER 1-800-424-8802; WITHIN CALIFORNIA CALL 1-800-852-7550 <br />