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State of California—Enviro.an n al Protection Agency <br /> Form Approved 9M8 No.2050-0039(Expirw 9.30-99) See Instructions On back of page 6. Department of Toxic Substances Conlroi <br /> Please print or type. fyrdr designed lar use on•lis@(12-pik awrihr. Sacramento,California <br /> Generators US EPA ID No Manifest Decumenr 2. Page 1 Inlormation in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST FCIA i Cori z 11 ar r <br /> 3. Germnw.r's Nam•and Moiling Add... T �N T-/ -{ r A. State Manifest Document Number <br /> I V' JIJ.L.�I�. l'� 1 F.l) 5 <br /> YN t C lu prfzrk:1<,--e. 2270100`8 <br /> h o f T u It cl P� B. State Generator's ID <br /> us) A. Generator's Phone,,�J'1 llHJZ-0 !'_,T/ r <br /> n <br /> sv 5. Transporter 1 Company Name 6. US EPA ID Number C. Sbte Tnnsp rrhrs ID[Ruerwd.1 <br /> sn <br /> T 1..Trana <br /> �' porter's Phone <br /> ODS AAIEtti'_AtV VALLEYW,iS!'CL•li_ A LUL t? f5 <br /> m. 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Tranaporter's ID Reserved.) <br /> O F. Transporters Phone <br /> Acre? Sjh Addrs s 10. US EPA ID Number G. State FaciliVs ID <br /> S' 1s{^l�f�F' (J <br /> pd RL. 000 1119081 161 <br /> N 5,100 CLAUS ROAD H. Facility's Phone <br /> C'-�O RIVIERitANK, CA 95:%7 JIG I AlLl 010 10 1119 1 G q 1 209-00"181 <br /> NQ 12. Containers 13. Total led. Unit <br /> U I1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Numberl No. T e Quantity Wt/Vol I. Wash Number <br /> a. NON RCRA HAZARDOUS WASTE LIQUID 5tae ' r <br /> .EPA/Other <br /> 3 �01LYwATt.f: t -.. — — -- -- [ f I r T c14 <br /> o N <br /> P. EPA/Ocher <br /> a <br /> T c. State <br /> o T <br /> c O <br /> R EPA/Other <br /> w d. State <br /> Z <br /> W - EPA/Other - <br /> W <br /> N <br /> J. Additional Descriptions far Materials Listed Above K. Handling Codes for Wastes UssedsAbove <br /> 6. <br /> g OILY WATERd. <br /> W <br /> 0 15. Special Handling Instructions and Additional Information LJ (v , Ayltic <br /> Z GLCIVtS <br /> _ EME RCENCY PHONE 209-667-8857 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accura vIy described above by proper shipPi ng name and are classifid,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I am a large q onlip 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 economicallyy I <br /> n pre fica66 and that I haw selected thq ractim6le method of treatment,storey or dispa oI currently available to me which minimizes the present and future threat to human heabh <br /> sed Bre environment;OR,if I am a smalluanti <br /> d' q h9sneraror,I have made a good faith effort to minimize mywaste. ste generation and select the bast waste manmatted ted that is <br /> available b ms and That I can afford. <br /> O} Printed/Type °{`�• ('. / �; Signature '!• Month Day Year <br /> Z ef/71 yllj �/"� Ur l� ;s"�t r y ) ) <br /> W T 17. Transporter 1 Acknowles anent of Recei tof Mohrlalt -' <br /> Primed/Typd Namr� Signatures Month Day Year <br /> W // <br /> Q 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> h <br /> T Printed/Typed Nam• Signer. Month Day Year <br /> W E <br /> � 1 <br /> LaJ 19. Discrepancy Indication Space <br /> Z F , <br /> A <br /> C <br /> L <br /> 1 20. Facility Owner or O arab!Certification of receipt of hazardous materials covered by this manifest sus t as noted in Item 19. <br /> T Printed/Typd Nams/ /Iu" / �/ Signahra onlh Dayy <br /> Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Green. TRANSPVnTE4 I--- <br /> EPA 8700-22 - <br />