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StateofCalitomirEnvironiganAl`Pro»cfian A cy <br /> Form Appropal OMB No.2B50,W39(Expires r30-99) See Instructions on back of page 6. Department of Toxic Substances cannel <br /> Please print I In type. Form A ignad for Ute of elr»(12-pit vwri»c Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA 10 No. Manifest Document 2. Page I Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal law. <br /> fl 't d fi 1 2 fl 3 5 4 1 -5 of 1 <br /> 3. Generator's Name and Mailing Address A. Shote Monifest Document Number <br /> RO-,ENTMAL TR UST CIO BANK (W ST(X--KION 20835415 <br /> h 24 SOUTH AMERICAN STREET,STOCKTON,CA 95M2 B. Sho»Ganerd d s ID <br /> A. Generoror'i Phone.( 209)948-0434 _ <br /> N - & Transporter 1 Company Name -6. US EPA ID Number C. Sfam Transpar»rs 1D(Rasa <br /> h .. .. <br /> m <br /> G - D, Transporter's Phone , <br /> ltlMK.l\.PI..i1/`6 VALLEY WASTE E � 3 <br /> -Q In 10 113 12 171817 tfi 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter',ID fReserved.I <br /> V Transporters Phone - <br /> iiii <br /> U i9Designated FacilityName and Site Address 10, US EPA ID Number G. Sla»Facility's ID <br /> sl NDUSTRIAL SEMICE OIL CO, INC, <br /> 0 1700 5.SOTO ST. H. Fo6liy,Phone <br /> w i.OS ANGELES, CA 9(:023 Q10 191914151.2 7 1018 <br /> Q 11. US DOT Description(including Proper Shi m Name,Hazard Class,and ID Num6er 1 -Containers 13. Total 14. Unit <br /> V U P (i 9Shipping I -I.."/i T (Orpnfity Wf/Vol I. Waste Number <br /> N= a.IkM RCCA HAZARLK)US WASTE LIQLAD ,rote 221 <br /> 3 G <br /> o (OIL &WATER) C t. EPA/Other <br /> E N ts b. Sizes <br /> E <br /> v R EPA/Other <br /> v A S: <br /> o T Sana <br /> m O jY. <br /> R lit 1/016er <br /> Fd. Stale <br /> Z <br /> W <br /> U EPA/Other <br /> w <br /> H <br /> J. Additional Descriptions for Ma»rials Used Above K. Handling Codes for Wastes Listed A6wa <br /> Z <br /> Q <br /> W O` WATER <br /> a <br /> Z <br /> O 15. Special Handling Instructions and Additional Information <br /> Q APF'R WRIAi E PROTECTIVE CLOTtiWv <br /> Z <br /> d1=3uERGENCY CONTACT'(209)652-8&110" <br /> � SEE E.R.G 171 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this conignmenlare fully and accurately described above by proper shipping name andara da»ified,pahed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulafion. <br /> J If I om a large quaraiy gene tar,I ertify that I have p ogran in place la/reduce the volume and toxicity f was»generated to the degree I have determined to be economical)yy <br /> o_ <br /> practicable and that I hhave selected the practicable method o trealment,storage,or disposol currently available tome which nrn mites the present and future threat re human healtls <br /> w and the environment,OR,if I am a small quantity generaro I has»myde goad pith effort to minimize mywPtn <br /> mus ousand select the bmf waste management method that is <br /> Oavailable to me and that I can afford. t..__ r, e""` - <;..,, <br /> y Printed/Typed Name Signature 'Monlh Day Year <br /> U _ <br /> Z <br /> w - 1 7 . Trans f»r 1 Acknowledgement of ReSillipt of Materials <br /> w E Prip»d/Typed Nome'" Signature - v Month Day Year <br /> If- <br /> u- B 1 r6ns r»r 2 Ackno ad amenf of ecei f o Material. <br /> O T Printed/Typed Name Signature Month Day Year <br /> w E <br /> n R <br /> V ) 19. Discrepancy Indication Space <br /> Z A <br /> C <br /> 20. Facility Owner or Operator Certification of race. t of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Prin»d/Typed Name Signature Manch Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />