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Department of Health Services <br />Stage of. <br />Calif —H®a ad WeM <br />Toxic Substances <br />Form <br />Approved <br />OMB4fo <br />California <br />Sacramento.ii <br />• Plepse <br />riot ort F Aad for Ch 6 <br />t. toes US EPA .ID No. nifest <br />UNIFORM HAZARDO No. <br />2. t Information in the shaded! t <br />Document <br />WASTE MANIFEST C <br />of not v�quired lyy Federal k <br />3. Generat r s Name and <br />A s <br />is <br />. 10, <br />Stockton, ta.; 9520 <br />e torte <br />4. 0%4rator's Phone <br />267 <br />6. Transporter t Company;Name 8. - US EPA ID Number <br />ii. Twrs <br />?e Transporter -2 Compo <br />Cj ZZ <br />9. Designated Facility Name and Site Address /0. US EPA 1D Number <br />tate IraCiihY'4 <br />Chemical Waste ft ut <br />85251 Old Skpl.in! Rd- <br />Kettlewn City Ca. 98259 T 0 0 0 6# 6 1 Y 1 7 <br />r, <br />12. Containers <br />13. Total` 14' <br />Quantity unit <br />tdfaate1D <br />11. US DOT DescAptioh (Including Proper Shipping Name, Hazard Class, and ID Number) <br />No. <br />Type <br />Wtivo <br />a. <br />` <br />Waste Oil motto �S;CAl�' � <br />f <br />" <br />Replated i+r7t4t only, ! i <br />o O <br />� <br />. <br />t <br />N <br />i <br />i <br />� r <br />i <br />if t Codes 9h~0 Abdo <br />7 { 5 `➢` 8 -0 <br />!sae. <br />�'T ..... 'i4.A o-Pwx _,. .. , . _ >�3 ... .. <y..• .. <br />Is , iy�l4andung Instructions and Additional Information <br />Gloves, safety. s . S .621 -054 <br />16. <br />GENERATOR'S CERTIFICATICIN: 1 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 <br />for transport by highway according to applicable <br />international and national government regulations. <br />1 <br />If I am a large quantity generator, I certify that l have a program in place to reduce the volume and <br />toxicity of waste generated to the degree 1 have <br />determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br />pte which minimises pre t� thro t4 human he and t environment; -.",if I am a small quantity' generator, I, t�ttaaye made a good <br />. that is available to nm and that f afford. ` <br />faith effortto minimize wa'steq ration a selec4 the ,best waste m nagemeM met <br />can <br />1 ': - <br />r <br />h <br />Printed/Ty Oftme SI <br />Month Day Year <br />1 T. Tran orter t Acknowi -Q >3. of Materials <br />R <br />A <br />N <br />PrIntd/ yped Name <br />tur <br />Month Day Year <br />S <br />P <br />O <br />18. Transporter 2 Acknowledgement of Recelpt of Materials, <br />R <br />T., <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />S <br />19. Discrepancy Indication Space <br />., <br />L <br />i, <br />20. Facility Owner or Operat ification of receipt of hazardous materials covered by this m!Vest est exce as noteO in hem 19. <br />T <br />Printed/Typed .Y <br />Signature <br />Month Day <br />Y <br />18°22 <br />-Name . _ <br />If <br />r (RIS A (' /aT) <br />Yeflow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br />EPA 870D--22 <br />(Rev. 9-88) Previous editions are obsolete.' <br />t <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 />