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J <br />J <br />U <br />U <br />r <br />.i <br />Mats of Caldomia—+lealth and Welfare Agency <br />Form Approv_ad OMB No. 2050-0039 (Expires 9-30-5 <br />Department of Health SeMces <br />Toxic Substances Cartrol Division <br />Sacramento, California <br />rheas <br />p.m. u, nw. ,�,..,., wa,v..o.. ......... .... ....._ <br />UNIFORM HAZARDOUS <br />.._ .-...... ...--.. _... <br />1. Generator's US EPA ID No. Manifest <br />2. Page t <br />Information in the shaded areas <br />WASTE MANIFEST <br />Document No. <br />C A C 0 <br />of <br />s no rewired by Federal leo. <br />3 Generator's Name end Mailing Address <br />Joe Thompson <br />A. Stall-MaMfeI Doc~ Number <br />j8197180 <br />7137 <br />B. State Generalities ID <br />E. Acawpo Road <br />Acampo, California 95220 <br />4. Generator's Phone (209 ) 369-6175 <br />H I A I H 1013 16 10121 <br />5, Transporter 1 Company Name 6. US EPA ID Number <br />C. State Tntnporiow s W <br />rranwoHa ePhOeadig) GSA 061111; <br />DILLARD TRUCKIN <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. Stasi Traeaportor'a <br />F. Tra uspeirter's Fl ose <br />g. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Faellity'a W <br />Petroleum Waste, Inc. <br />16 171512 171111 <br />Lokern Road <br />N. FaclMy's <br />Buttonwillow, California 93206 <br />(605) 762-7341 <br />12. Conte inere <br />13. Total <br />14 <br />(. <br />11. US DOT Description (Including Proper Shipping Na, Hazard Claes, and ID Number) <br />No" <br />Quantity <br />Unit <br />Unit <br />Waste No. <br />No. Type <br />WI/vol <br />a <br />State <br />611 <br />G <br />Soil with Petroleum Hydrocarbons <br />EPA/Dtn <br />E <br />California Regulated Material Only <br />j <br />RCRA axwwt <br />N <br />F <br />E <br />b <br />Sate <br />R <br />EPA/OHM <br />A <br />T <br />D <br />R <br />c <br />State <br />E A/Olhw <br />d <br />State <br />EPA r Other <br />J. Addhlonal Descriptions for Ma(adata Listed Above <br />K. H"Ing Codes for Wast" <br />Listed Above <br />a. <br />b. <br />Soil 99.5% <br />a <br />d. <br />Petroleum Hydrocarbons 0.87' <br />15. Special Handling Instructions and Additional Information <br />Profile ♦G -667 - <br />PROPER PROTECTIVE CLOTHING <br />16. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping nerve <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 />It 1 em a large quantity generator, I cerlity that I have s 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 sa' ctad the practicabie method of treatment, storage, or disposal currently available to me which minimize. the <br />present and future threat to human health and the environment; OR. If 1 am a small quantity generator, 1 have made a good faith effort to minimize my waste <br />generation and select the beat waste management method that Is available to ms nq that I can afford. <br />009, /Typed ante Signe sire Month Day Year <br />d a ! / r <br />17. Transporter / Acknowledge at of Recei of Materials .. i <br />R <br />A <br />N <br />Printed/Typed Name <br />Signature .' �' Month Day Year <br />S <br />r <br />P <br />O <br />. T aep 18ner 2 Acknowledgement of Receipt of taterials - <br />R <br />Prirded/Typed Name <br />Signature Month Day Yen <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in ham 19. <br />TSignature <br />y <br />Printed/ Typed Name <br />Month Day Year <br />DHS 8022A(1/66) Do Not Write Below This Line YELLOW: GENERATOR RETAINS <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. <br />