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I Form Appro it OMB No.2050-0038(Expires 0-30-9 1) Department of Health Servieee <br /> Pit eess not thype. (Form designed for use on sliteAftif,h typewriter). <br /> Substances Control Divisionler). Sacramento.Calltornie <br /> IFORM HAZARDOUS na,.for's US EPA ID No. Manlleat Papa 1 <br /> Informaion In the shaded great <br /> WASTE MANIFEST T Document No. <br /> .+ A k�. J J 517161 ] -7 of is not required by Federal law. <br /> 3. Oensrator'a Name and Meriting Address A. Slate Manlbel Document Number <br /> t1c�t:,itL:i�l LitVkCNll', AAL ScR'JI4ES 8 <br /> FIl IC4 4, NID"Jal i CA x4W B. State Gaesrelor's ID <br /> 4. Generelor's Phone( .I1J 7S,i ik 44i0 H Al -101114 41914 <br /> N5, Treneponer 1 Company Name C O J;W e. US EPA ID Number C. State Transporter s ID <br /> 7 p <br /> D. Trane oner's Phone <br /> m ]. Traesporter 2 Company Name B. US EPA ID Number E. State Tran.poner's ID <br /> 0 <br /> C) F. Tnnaportgr'e Phone <br /> } 6. Designated Facility Name and Site Address /0. US EPA ID Number G. Slate Facility's ID <br /> < cJl i� BCRVICES C AD 9 B 0 9 5 7 6 1 <br /> M H. Facility's Phone <br /> r-IZ C A093068576I BOO 7 - 284 <br /> 12. Containers 13. Total 14. <br /> o 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID NumberL <br /> OesntltY Unll Waste No. <br /> No. Type V Vol <br /> ~` WWASTE PETROLEUM OILS. NOS, COMI;USTIBLL UQL'tp, state �!1 <br /> 0)= 0 PIA 1270 <br /> 0 E EPA/Other <br /> N 10 11 a <br /> E b. <br /> d R Siete <br /> A <br /> T <br /> H 0 EPA/Other <br /> R <. <br /> 8 Slab <br /> m <br /> EPA/gher <br /> w d. <br /> stats - <br /> w <br /> U <br /> w EPA/qMr <br /> mJ. Additional Descriptions for Materiels Listed Above K. Handling Cotlae for Wulss Listed Above <br /> 2 <br /> 0 a. b. <br /> w 1.1 Weate ot1 with an unckilwinlned an,o(uyt of hak)gena <br /> 1.2 • Waals Water d. <br /> J <br /> < <br /> O e. .>pwV Y .. <br /> < 16. Special Handling Instructions and Additional Information Fill <br /> Z ? Xr <br /> ViI Pint�;dlve ClothingJAN S 1 Ir.-n <br /> < NVIR0i1IMElNTAL HEALTH <br /> 'B PERMIT/SERVICES <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents ql this consignment are fully and accurately described above by proper shipping name <br /> -J+ <br /> and are classified,pecked,marked,and labeled,and are in all respects In proper condition for transport by highway according to applicable International and <br /> W national government regulations. <br /> G If I em a large quantity generator,1 certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> U to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat 10 human health and the environment;OR,If I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the beet waste management method that Is available to me and the!1 can afford. <br /> Z <br /> W Printed/Typed Name Signature <br /> Month Day Year <br /> w <, <br /> WR 17. Tranaponer I Acknowledgement of Receipt of Materials <br /> Z A Printed/Typed Neme <br /> < N Signature Month Day Yes, <br /> S i ' . _ I <br /> w O 18. Tranel 2 Acknowledgement of Receipt--of <br /> N a <br /> VT Printed/Typed Name $1 nature E Month Day, Year <br /> Z_ <br /> Ig. Discrepancy Indication Space I i <br /> ,F, Shoed �c Mcdeim Cv\,� ,C.err,.ol t <br /> 2C6 <br /> L <br /> I F20, Facility Owner or Operator Cenlficeofreceipt of hazardous materia scovered by this manifest exoaTy ted/Typed Name <br /> Signature Month Day Year <br /> DHA 6022 A(I/!)e) <br /> EPA e]00-22 Do Not Write Below This Line <br /> (Rev.WMBB)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />