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5bfe o1 Califomio—Enviranmemal Protection Agency <br />Form Approved OMS No. 2050-0039 (Expires 930-94) 5!! IDSTTYg�laT13 Op f2atl( O page 6. Deponmem of Taxi S.bnoecn Co.. <br />Please orim o, Nee. Por. dawned far use on .lift 112-oilch) tvzo wnftc Sacromenro, California <br />DO NOT WRITE BELOW THIS UNE. <br />Blue, GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC SW2A P/M To- 00 8n. 4M Srvro—, CA 059120400 <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page I <br />Information in Me shaded areas <br />UNIFORM HAZARDOUS <br />s not required by Federal law. <br />WASTE MANIFEST <br />CAC 0 0 0 9 7 0 4 � 4 0 0 0 0 <br />1 <br />1 of 1 <br />3. Generator's Nome and Mailing Address <br />AF MmIi1M'Ooctsmerd <br />qy� <br />CITY OF TRACY 520 TRACY BLVD. <br />TRACY, CA 95376 ATTN: PAUL VER24A <br />Oeriembr�lD� m�;y" f,� <br />A. Generator', Phone (209) 836-4420 <br />_ . 4'r <br />_b e —, <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />.ID D <br />b <br />PETROLEUM RECYCLING CORP. 8 1 5 <br />tu <br />7. Transporter 2 Company Name 8. US EPA ID Number b <br />"Q <br />o �.W <br />9. Designated Facifity Nome and Simi Address 10. US EPA ID Number <br />" <br />PETROLEUM RECYCLING CORP. <br />13331 NORTH HIGHWAY 33 <br />PATTERSON, A. <br />11.' US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) 12. Comainen <br />No. Type <br />13. Total 14. Unit <br />Vol <br />a. NON RCRA-,HAZARDOUS WASTE LIQUID <br />E <br />.. (WATER," OIL) 01011 TITO <br />7G'' <br />Nb. <br />..._. <br />.:-. JA <br />E <br />R <br />A <br />O <br />R <br />, <br />d <br />15. -Special Handling Instructions and Additional Information <br />- <br />SITE: <br />24 HR. EMERGENCY CONTACT: 1-800-874-4444 <br />68 E. ELEVENTH ST. <br />TRACY, CA <br />24 HR. EMERGENCY RESPONSE: CHEN TEL INC. 1-800-255-3924 <br />APPROPRIATE P <br />16. GENERATOR'S CERTIEICATION: I hereby declare that the contents of the comfgmnsm or. fully and accurately described above by proper shipping name and are classified, <br />pocked, marked, and labeled, and aro in all respects in proper condition far transport by highway according to applicable federal, stole and international lows. <br />If 1 am a large quantity generator, I certify that I how a program in place to reduce the volume and toxicity of waste generated to the degree I haw determined to be <br />economically practicable and that I have selected M. practicable method of Feofinent, storage, or disposal currently available to me which minimizes the present and future <br />threat to human health and the environments OR, R 1 am a small quantity generator, 1 haw made a good Iaith effort to minimize my waste generation and select the best <br />warts mono ement method that is available to me and than I can afford. <br />/Typed Name I <br />SS[SWra 1 <br />If'. "� 1, �C•,nn' <br />/�oMl� Day <br />/ <br />�'t11 e^.�� U`�P�, <br />m,Aarl �. <br />U <br />T <br />17. Tnompoiftr 1 Acknowittignmeent of Receipt of Materials <br />e <br />A <br />st <br />Pr' Nome <br />HNreL RSdA) <br />r <br />Oay <br />°Z <br />0 <br />1B. torn rtn 2 Acknowed amort of Receipt of Marenak <br />T <br />Printed/Typed Nome <br />Signotero <br />Month Day Yea, <br />e <br />19. Discrepancy Indication Space <br />E <br />A <br />C <br />1 <br />k <br />1 <br />20. Facility Owner or rarer Certification of receipt of hazardous material, covered by this .embed except as noted in Item 19. <br />T <br />Printed/Typed Name Sigrsawre <br />Month Day year <br />r <br />DO NOT WRITE BELOW THIS UNE. <br />Blue, GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC SW2A P/M To- 00 8n. 4M Srvro—, CA 059120400 <br />