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T <br /> (State of Cellfomle-Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2060-0039(Ex Plfes 9-30-91 Toxic Substances Control Division <br /> Please print or type. (Form designed for use on eflfe(1. .1ch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generetor'a US EPA ID No. Manifest 2. Page 1 Informallon In the shaded areas <br /> Document No. <br /> WASTE MANIFEST ,4 o a of 1 ie not required by Federal few. <br /> 3. Generator's Name and Meiling Address A. State Manifest D cu en Number <br /> 89�d2007 <br /> B. 91e1e Generator's ID <br /> 4. Generator's Phone( ) R ' f 7�- <br /> 6. Transporter I Company Name 6. U9 EPA ID Number C. State Transporter's 10 PI <br /> n DILLARD TRUCKING I CI Al 111 91 81 11 61 91 21 81 01 9 D. Transporter's Phone 415 1, 634-0567 <br /> N <br /> 7. Transporter 2 Company Name 6. US EPA ID Number E. State Transporter's ID <br /> ap <br /> §. F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Slate Facility's ID <br /> Erickson, Inc. <br /> 255 Parr Blvd. H. Facility's Phone <br /> Q Richmond, Ca. 94801 <br /> iI CI AlDI 01 01 91 41 61 6 31 91 2 If 4 15 1 215- M93 <br /> am 12. Containers 13. Total 11. I. <br /> 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,end ID Number) Ouenttry Unit Waale No. <br /> u_ No. Type WI/Vol <br /> JV <br /> e. State 512 <br /> ZG Waste Empty Storage Tanks EPA/O r <br /> E California Regulated Waste Only 0 0 2 T P 1 0 5 0 0 P one <br /> N <br /> E b. _ State <br /> N R <br /> A <br /> T EPA/Other <br /> v O <br /> V R C. State <br /> 8 EPA/Other <br /> 2 '' d. Stale <br /> Z <br /> U � <br /> EPAIO her <br /> W T1, <br /> 2 J. Additional Descriptions for Materials Listed Above 1 K. Handling Codes for Wastes Listed Above <br /> 0. Empty t� /''r0 stank, #2632 iced with lbs. ` b' <br /> w dry lc Emptli I. ,)tpnk, #2633 iced' With <br /> D'y '/ lbs. dry ids. p. d. <br /> Z <br /> o <br /> r 16, Special Handling Instructions and Additional Inlormelion <br /> Z <br /> J <br /> V 16. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <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 /> IL national government regulations. <br /> to <br /> cc 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 determined <br /> p to be economically practicable and that have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> >- present and future threat to 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 best waste management method that Is available to me and that I cen.Aflurd. <br /> Z <br /> WPrinted/Typed Name Sign urp `` Month Day Year <br /> X <br /> W rY1 `fk <br /> WT 17. Transporter I Acknowledgement of Receipt of Materiels <br /> Z R <br /> QA P�rint-e-dlIfyp Name Signature s--"„' ,' Month Day Year <br /> LL a <br /> Is <br /> P 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W O <br /> UR Printed l Typed Name Signature Month Day Year <br /> E <br /> 2 <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. i <br /> T <br /> y Printed/Typed Name Signature Month Day Peer <br /> DHS 5022 A(1/fib) Do Not Write Below This Line <br /> PA 870&-22 <br /> iev.9-68)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br /> i <br />