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De� a yeelth Services <br /> `.State of California—Heahh and Welfare Agency �-/ Toxic Su"et trol Division <br /> Form Approved OMB No.2050-0039(Expires 9.30-81) _ 1 alilornia <br /> Please p::U:N%�ORM; <br /> t or type. (Fdesigned for use on elite(12-pitch typewriter). Menifeat 2. Paget S <br /> HAZARDOUS Generator's US EPA ID No. Document No. Into motion In the shaded are , <br /> STE MANIFEST of is not required by Federal law. <br /> A. Stets Menifeat D�Lu���nnneryt N mbar <br /> . GanBrator'ellame and Melfyno rasa (1 Q('>) O <br /> 1)(pr�h�/�L / �,CU B. State Generator's 1D <br /> 4. HeR ator sCJP`hhlo (2 ) <br /> 5. Transporter t Campeny Neme S. US EPA ID Number C. State Tire 10 G <br /> m D. Transporter'a Phone <br /> N <br /> n <br /> �� 7. Transporter 2 Company Name <br /> B. US EPA ID Number E. State Transporter ID <br /> m F. Trenaporter's Phone <br /> 0 I,,JE.S�Q✓ham p <br /> T 9. Designated Facility Name and Site Address 10. US EPA W Number G. State Facility's ID <br /> Refineries Service <br /> LA 13331 N. HWY. 33 H. Facility's Phone <br /> d < <br /> Patterson, Ca. 95363 <br /> 0¢ 2. Containers 3. Tote ' 14. I. <br /> o 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit <br /> V) Waste No. <br /> No. Type Wi Not <br /> O J State <br /> OD Non RCRA Hazardous Waste Liquid <br /> .A EPA/Other <br /> v'S c Q <br /> 3 N St <br /> E b. <br /> R <br /> A EPA/Other <br /> m T <br /> e O Stale <br /> a R c. <br /> f <br /> g EPA/Other <br /> m <br /> Lu d -- State <br /> 2 EPA/Ocher <br /> W <br /> U <br /> w K. Handling Codas for Wastes Listed Above <br /> W J. Additional Descriptions far Materials Listed Above <br /> Z a. b. <br /> O <br /> _-_a -- y p _—.___.._ _ <br /> H PeEroTeum H dr0r7Scn'A prox <br /> Water Approx% d' <br /> Z Sludge Approx% <br /> 0 <br /> f 15. Special Handling Instructions and Additional Information <br /> Z Wear Gloves, Goggles_& Protective Clothing <br /> In Case Of Emergency Or Spill Call Respones (209) 892-6742 DIKE AND CONTAIN <br /> J <br /> J <br /> U 6. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this openconsignmentcondition <br /> are Itra and accurately y described above pl proper shipping name <br /> J <br /> and are classified,pecked marked and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> a national government regulations. <br /> W <br /> X If I am a large quantity generator,I that I that I have a program in place to reduce the volume for toxicity of waste generated to the degree I have determine <br /> O pr be economically hreati to hu and that I have selected the nt;OR,If I method of treatment, nerape,or disphave <br /> d currentlygood available to me which minimizes the <br /> present and lunare threat to human health and the environment;OR,ii I am a emelt quantity generator,I have made a pond faith effort to minimize my waste <br /> generation and select the best waste management method that is available to me and that I can afford. <br /> U <br /> W Printed/Typed Na/ma Signature Month Day Year <br /> W16131121 cX <br /> .0 Cc, (S <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W R Month Day Year <br /> < A P /Ty ed Name Signet <br /> o <br /> S C� <br /> Pill b 18. Transporter 2 Acknowledcement of Receipt of Materials <br /> U) RA Printed/Typed Name Ignsture Month Day Year <br /> E <br /> ZIq_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted In Item 19. <br /> yPrinted/Typed Name Signature Month Dey Year <br /> DHS 0022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9-88)Previous editions are obsolete. <br /> To: P.O. Box 400, Sacramento, CA 958120400 <br />