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State of C.IIFo ma—Environ enrol Prylectwn AgFnq r e 'W'`bt� r , b'�I '�. '. s <br /> Form Approved OMB No.2050-0039yEzpmee 9-30.991 : See Ins"diOOBi011'; Dopar e�i6zi be Cunhpl <br /> Please pnnt or type,. form des fined ynondilefi2•prleh) :iror. - +'. may. S it - 'PIT! <br /> b Saeralneato,CaLlormd.,..!'"'r <br /> 1. Genenbr s US EPA ID No Manifest Document Nq"• Paga 1 'Informal n in the shaded as c Y'- <br /> UNffORM HA RDOUS al tr edb Federal to l� <br /> WASTE MANIFESTjai <br /> ! 14a a a .qa r y <br /> 3. Ce Imttor's Name and Mailing Addna, - <br /> VAN DF POL ENT, <br /> P.O. BOX 1107, STOCKTON, CA195201 <br /> A. Generators Phon. 1 2gq )466-5921 <br /> N 5. Transporter I Company Name 6. US EPA ID Number <br /> res <br /> o NOR CAL OIL, INC. IC IA ID 19 IR 121411171 <br /> Go 7. Transporter 2 Company Name 8. US EPA ID Number <br /> J <br /> Q <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> A z INDUSTRIAL SERVICE OIL CO. <br /> —1ce 1700 S. SOTO ST. <br /> -4 LL_ A. y <br /> �UJ I7. US DOT De,cri lion Inducing Pre Proper Shi Name,Hazard Class,and ID Number 12. Containers 13. Total X14. Unit <br /> P 1 9 P Shipping 1 No. Type ''Quantity WI/Vol <br /> 10 Z a. <br /> A NON—RCRA HAZARDOUS WASTE LIQUID <br /> 3 c , . <br /> A; E (WATER s SIACX;E) 01011 T" T <br /> 6 N <br /> ro E <br /> v R <br /> v A <br /> m O �. <br /> R <br /> z <br /> w d <br /> Z <br /> U <br /> w <br /> Z <br /> Z <br /> O <br /> 6 <br /> as <br /> W <br /> K <br /> J <br /> Z <br /> Z 15. Special Handling Instructions and Additional Informationrt y, <br /> a APPROPRIATE PROTECTIVE CLOTHING �SIT$�AC)DAESSs <br /> "DIMF24CY CONTACTS (209)541-9145" n 3147 S. $L L10RAll0 <br /> l— SEE E.R.G. 171 .', <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the zaniest,of this wnsinusnt are Fully and accurately described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition Mr transport by highway according to applicable international and nagonol government regulations. <br /> a..'... <br /> If I am a large anti enerotor,I certify that I have a pro in lace to reduce the of e <br /> B 9u e h p p Y tax y f t 'ge en(ed to the degree I have determined to ba Konomically <br /> Npracticable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a,moll quantity gm eratoq 1 have made a good faith effort to m'nimise n and s76t the best waste management method that is <br /> cs: <br /> O availab6 to me and that I can afford. _ . . <br /> } Printed/Type N m �� Signature Mumlh Day Year <br /> Z r L <br /> w o 17. Tr T &, car 1 cknowla em of Recei t o Moteb riaIr <br /> w I Printed/Typed Name Signator Month 'Day Year <br /> f S <br /> w P <br /> LL E 18. Transport*,2 Acknowled ement of Receipt of Materials '' <br /> O 1 P,mI.d/Typu1 Noma 5ignat.ra _ Month Day Year <br /> w <br /> Qty ; ,2 <br /> (} 19. Discrepancy Indication Space <br /> Z F <br /> _ A <br /> C <br /> L <br /> 1 20. Facili Owner or Operator Certification of receipt of h...rdousamteriol,cov..d b this manifest asap t es noted in ON.19. <br /> T PrintM <br /> ed/Typd N;e Signature onth r Day Year <br /> Y <br /> DO NOT WRITE 6LOW THIS <br /> DISC 8022A 14/971 <br /> EPA 8700-22 Green: TRANSPORTER RETAINS <br />