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%Slate of Oelitornie- 1-lealth and Welfare Agency ��Q <br /> Form APP OMB No.2050 039(Expires 9.3� $Ce IO8frI1Cfi005 On of Page 6 Department of Health Services <br /> C'ea se pdw or'„pe. (Fmm designed for use on elite,la-p;rcA rypewrneq. and Front of je Toxic Substances Control Division <br /> Sacramento,California <br /> rn UNIFORM HAZARDOUS L Generator's US EPA ID No. Manifest 2. Page f <br /> V WASTE MANIFEST Document No. Information in the shaded areas <br /> \ C A 4 of 1 is not required by Federal law. <br /> 3. Generator's Neme antl Meiling Address NCZ JOB SITE: CASOO SERVICE STAT I A. State Manifest Document Number <br /> DARPE� lin 89493281 <br /> 3450 EI Camino Avenue 749 E. Charter Way, <br /> Seres, CA 95307 Stockton, California B. Slate Generator's ID <br /> 4. Generator's Phone(209) 537-0771 <br /> h <br /> S. Transporter 1 Company Name <br /> n 6. US EPA ID Number C. State Transporter's ID 003773/81 <br /> ti H S H Ship p Service Company CAD 0 0 4 7 7 1 1 6 8 D. Transporter',PhoneM <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporter',ID <br /> O <br /> m F. Trenapoder's Phone <br /> 9. Designated Facility Name and Site Address 10. U3 EPA ID Number G. Slate Facility's ID <br /> J H E H Ship Service Company <br /> CAD 0 0141717 <br /> CIO 220 China Basin Street H. Facility's Phone <br /> San Francisco, CA 94107 CAD 0 0 4 7 7 1 1 6 8 (415) 543-48 <br /> "V7 0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number 12. Containers 13. Total 7 Quantity No. Type L, RES I DUE WASTE 01 L TANK- GfT) r E (CALIFORNIA ONLY REC7JLATED WASTE) EPA/Other <br /> 3 E b 01011 T P 010121810 __ <br /> o R RESIDUE ASSOCIATED PIPING state 513 <br /> m T (CALIFORNIA ONLY REGULATED WASTE) /Other <br /> V O 0 1 5 Cly 0 0 31010 <br /> P <br /> 0p R C. <br /> OSiete <br /> 241 <br /> HAZARDOUS WASTE LIQUID, N.O.S. ORM-E NA 9189 G EPA/Other <br /> w d. 01013 D M 010111615 <br /> Z Slate <br /> w <br /> U <br /> � EPA/Other <br /> J. Additional Descriptions for Materials Listed Above <br /> Z K. Handling Codes for Wastes Listed Above <br /> - <br /> 0 PUMPED CUT 280 gallon tank and associated piping last a. b. <br /> a containing waste oil . Tank inerted with dry ice for 01 01 <br /> transport, C. It. <br /> Z FUEL OIL AND WATER 01 <br /> 0 <br /> - 15. Special Handling Instructions and Additional Information <br /> Z <br /> 2 <br /> APPROPRIATE PROTECTIVE CLM I NG A1Z RESPIRATOR. <br /> J <br /> ' U <br /> 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> -� <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 /> Il national government regulations. <br /> rn <br /> If I em a large quantity generator,I teddy that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> 0 to be economically practicable and that I have selected the practicable method of Ireatm nt,storage or disposal currently available to me which minimizes the <br /> } present and future threat to human health and the environment;OR, it I em a small en'y general ve e a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me d at I can rd <br /> Z <br /> W Printed/Typed Name <br /> O Signature Month Day Year <br /> w <br /> �jT /U SJGG�aA-I Ll/Y7 0 1 1 2 9 0 <br /> wR 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name <br /> Z Signelure Month Day Year <br /> 1 <br /> IL "s FREDERICK TYRONE NEAL 1 r0r1� 1 <br /> O p <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 Printed/Typed Neme Signature <br /> Month Day Year <br /> Cl E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 20. Facility Owner or Op for Certification of receipt of hazardous materials covered by this manif 1 exce s noted(o Item I . <br /> T <br /> Y <br /> Pri 11 rdl III Neme ,� n / Signelure / Month Do earO <br /> DHS 8022 A(1/88) Do Not Write Below This Line (� <br /> EPA 8700-22 <br /> (Rev.988)Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 3000, Sacramento, CA 95812 I <br />