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State of Calif, miranmemd Protection Agency <br /> Farm Apym„ed 8 .2050.0039(Expires 9.3"A) - See Instructions on back ,age 6. Deparonem of Toxic Substances Contra <br /> Plea"prim or y designed fee uee a elite(12p A,1pwriM. Sarramemo,Colifomw <br /> I RM HAZARDOUS 1. Generala/s US EPA ID No. Manifest Document No. 2. Page I Information in the shaded are. <br /> is not required by Federal law. <br /> (JA TE MANIFEST CIAIC1010101 19181916181 81 11 °f1 <br /> 3. G+me, V's and Mauling Address <br /> DONALD R. COLVIN <br /> ul <br /> 3565 Ridgewood Ct. , Concord, CA 94518-1535 SaaFeGsaala: lDO, _r: .,,, <br /> 4. Gen..aes Ph.. (510) 682-0392 <br /> b 5 Tromps n.r 1 Company Name 6. US EPA ID Number C. Sate Trcros cr ten's ID - L/ <br /> INOR <br /> CAD 9 8 2 4 1 7 2 5 5 D..Tr°.parte,'"'"" (209')7 667--16692 CAL Q <br /> r 7. Tronspomr 2 Company Name R. US EPA ID Number I E. State Transporteh ID <br /> U <br /> IrF...T—porta'x Phase,.. <br /> 9. Designated led Facility Noand Site Address 10. US EPA ID Number G. Sate-Facility's ID <br /> oREFINERIES SERVICE CAD 01813 116161712181 <br /> W 13331 N. Hwy 33 H..Fa Iity',Pha,e <br /> C:) a Patterson CA 95363 CAD 0 8 3 11616171218, _ <br /> U 12. Containers 13- Total 14. Une <br /> 00 Z 11. US DOT Description(including Proper Shipping Name,Hazard Gass,and ID Number) No, i QuantityWt/vol 1. Waste Number <br /> CO 3 a. NON-RHRCRA HAZARDOUS WASTE LIQUID S"°° 223 <br /> 07 Ci E <br /> (WATERR & OIL) 01011 T T / G EPA Oher <br /> m N b. Stine <br /> a0 E <br /> RTEPA/' OtMr <br /> y A <br /> F T e state <br /> O <br /> Cd R 1 EPAJOt <br /> Zd. ! State <br /> W <br /> U EPA/Other <br /> W <br /> N <br /> Z .J..Addiliaral Descriptions for Materials Listed Above K—Handling Codes for W,stes Listed Above <br /> JTANK BOTTOM WASTE,: b. <br /> d. <br /> a <br /> Z <br /> Q 15. Special Handling Instructions and Additional Information <br /> a APPROPRIATE PROTECTIVE CLOTHING <br /> z "EMERGENCY CONTACT: (209) 667-6692" <br /> = SEE E.R.G. PAGE 31 <br /> t- <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> a packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> V <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 to be <br /> economicaily practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> ythreat to human health and the environment;OR, R 1 am a small q...*generator, I have made a good faith effort to minimize my.,to gisneradan and select the best <br /> waste masa ement method that is available a me and that I can afford. <br /> O Printed/Typed NameMARIIN Sig re MOMIy` Day Yea <br /> > DONALD R. COLVIN L/j C3 <br /> U T 17. Transporter 1 Acknowledgement of Receipt ofJOugeri.Is <br /> W AR Primed/Typed Name . Signature Day ea� <br /> � N <br /> W x <br /> 0 18. Trans anter 2 Ackwwled ensent of Recei t of Materia s <br /> W i Primed/Typed Name n re Month Day Year <br /> W e <br /> O v <br /> W 19. Discrepancy Indication Space <br /> U3 <br /> Q F <br /> U A <br /> Z C <br /> I <br /> L <br /> 1 20. Focilily Owner or ermon r Certifications of receipt of hazardws materials covered by this manifest except an noted in Item 19. <br /> T Primed/Typed Name SignaNre Month Day Year <br /> DO NOT WRITE BELOW THIS UNE. <br /> DTSC g022A 7 White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> ( /92) To: P.O. Box 3000, Sacramento, CA 95812 <br /> A DO--2] <br /> fr <br />