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State of CallfAriio—Environmental Pretension Agency J <br /> Form Approved OMB No.2050-0039(Expires 9-309d) - See Instructions on back of Page 6. Department of Toxic Substances Control <br /> Pkme-trim or type. Form designed for use cm elite(12pihh) rifer. Sacramento,California <br /> �LNIFORM HAZARDOUS1"7jt--jrj <br /> rales US EPA ID No. Mended DocumentTrseP— 2. page 1 Informaton in the shaded prem <br /> WASTE MANIFEST is not required by Federal law. <br /> 8 7 7 °' 1 <br /> 3. C»neraror's Name and Mvilirp Address 1Ai Store Man fest Doth + <br /> n LLOYD GUMS <br /> 731 Birchwood Dr. , Lodi , CA 95240 a State Generator,ID <br /> d' cenerato,tPhmro 1209) 333-1939 1 1 1 1 1 1 <br /> S. Transporter 1 Company Name 6. US EPA ID Number C: State Transporters ID <br /> op NOR CAL OIL ClAlD1 9181 21 41 11 71 21 51 9,Tramporte,Phone (209) 667-6692 <br /> 7. Transporter 2 Com Name <br /> a W Pa^Y 8. US EPA ID Number 8, Stafo Transporter's ID <br /> U �I <br /> f Uansporte s Phena —` 71 <br /> a <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> $ Fm I y ID <br /> T'- A <br /> Refineries Service 1 <br /> 2 13331 N. Hwy 33 racmy,Phone <br /> �u 5 _ 800 874.4444 <br /> Z 11. US DOT Deutiption(including Proper Shipping Name,Hazard Class,and ID Number) 12 Coma ncr, 19. Toml 14. Urn —� <br /> 7NO. T e Quantity Wt/vol I Waste Number <br /> CV~ a NON-RCRA HAZARDOUS WASTE LIQUIDT N b (WATER & OIL) T Ggo °heY3 <br /> E <br /> R <br /> A or <br /> T C. <br /> O State <br /> dc R 7 <br /> l <br /> W C <br /> N <br /> 0 'Additional Descriptions for Materials Listed Above k. Hari <br /> g. <br /> PRODUCT LINE WASTE a <br /> r. <br /> RINSATE <br /> e. <br /> a <br /> 15 $peaol H.rdfinci instructiond Additional I .motion <br /> a APPROPRIATE PROTECTIVE CLOTHING <br /> Z <br /> W "EMERGENCY CONTACT: (209) 667-6692"� SEE E.R.G. PAGE 31 <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare gust the contents of the consignment are fully and accurately described above by proper shipping name and oreclassified, <br /> V .I <br /> packed,marked,and labeled,and are in all respects in proper condition im transport by highway according to applicable federal,trate and international laws. 'SI1 <br /> If I am a large quantity generator, I certify that I have g program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be i <br /> economically practicable and that 1 have selected the practicable method of treatment.storage,or disposal currently available to me which minimizes the present and fu <br /> Wre ') <br /> G threat to human heath and the environment;OR, R 1 am a small quantity generator, I have made a good faits effort to minimize my waste generation and select the best <br /> N <br /> � wmto management method that is available to me and that I can afford. <br /> O Printed/Typed Name Martin Ihorpe agent or Signature 1_ Momh Day rem <br /> Lloyd Gums I a t.ct ;,p - <br /> Z T 17. Transporter) Acknowded nt of It"Apt of Materia <br /> W i Printed/T m / �" _ SigrwNre .1 Day em <br /> P <br /> � IS. Tran .ter 2 Acknowled M of Ittroeipt of MvNriog <br /> T Printed/Typed Name Signature Month Doy year <br /> 0 <br /> Q <br /> 1W 19. Discrepancy Indication Space <br /> U F <br /> A <br /> Z C <br /> 1 <br /> L <br /> 1 20. FadF Owrror or Cefwor Certification of racer of hazardous malerials covered by this manifest excenst as noted in gem 19. <br /> T Prinbd/Typed Name Signalom Month Day year 1I <br /> y <br /> DO NOT WRITE BELOW THIS LINE. <br /> OTSC 8022A (7/92) r .� <br /> EPA 8700-22 <br /> ;,P,, ,MFJER.A70R RETAINS <br />