Laserfiche WebLink
Steple of Califomla—Health and Welfare Agency <br />F?1m of <br />OMB No. 2050-0039 (Expires 9-30.91) <br />'PI t t (Fo m desi ned for use on elite 0 <br />H <br />n <br />m <br />N< <br />U <br />MIX <br />C <br />0 <br />4W <br />z <br />009 <br />3 <br />2 <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />ease prin <br />or ype. r D <br />vv^^•••_•. <br />1.'Gamin for s US EPA ID No. Manifest <br />ape 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />CAC 10 0 10 1 1112,6171213D°�u7nt5"°0 <br />1 of 1 <br />is not required by Federal law_ <br />3. Generator's Name and Mailing Address <br />A. Slate Manifest DNumber <br />Brooks Product <br />89'9b 3012 <br />B. State Generator's ID <br />2441 W. Charter WYy Stockton, Ca. 95206 <br />4. Generator's Phone ( 20% 464-7696 <br />1 1 1 1 1 1 1 1 <br />5. Transporter 1 Company Name 8. US EPA ID Number <br />n <br />C. State Transporter's ID O r7 J <br />D. Transporter's Phone (209) 892-6742 <br />Refineries Service a Aj Di oi 81 11 11 61 61 71 2j <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporier's ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />Refineries Service <br />H. Facility's Phone <br />13331 N. HWY. 33 <br />Patterson, Ca. 95363 <br />12. Containers <br />13. Total <br />14. <br />1. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />West. No. <br />No. Type <br />Wt/Vol <br />e' Hon RCRA Hazardous Waste Liquid <br />Stata223 <br />EPA/O her <br />°e <br />Rinsate 9189 <br />N <br />0101 1WFMPT <br />E <br />b. <br />State <br />R <br />EPA/Other <br />A <br />T <br />O <br />R <br />C. in W <br />State <br />NOV 11990 <br />EPA/Other <br />d <br />State <br />PERMIT/SERVICES <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b. <br />Petroleum Hydrocarbon Approx$ if <br />Water Approx% <br />C. <br />d. <br />Sludge Approx$ 0 <br />15. Special Handling Instructions and Additional Information <br />Wear Gloves, Goggles & Protective Clothing <br />In Case Of Emergency Or Spill Call Respones (209) 892-6742 D= AND CONTAIN <br />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 />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 determined <br />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 end 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 />generation and select the beat wsafe management method that is available to me and that 1 can afford. <br />Printed/Typed Name <br />Signature Month Day Year <br />//ilQy22 za✓E" S <br />1 11 CI fol 94 <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Prints Typed Name <br />Signator Month Day Year <br />N <br />S <br />y1C� � rti I� <br />✓� � /I C1 If 1 5110 <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Item 19. <br />y <br />Printed/Typed Name <br />Signature Month Day Year <br />DHS 8622 A (1 /88) Do Not Write Below This Line <br />EPA 8703--22 <br />(Rev. 9-88) Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 4DO, Socromento, CA 956120400 <br />