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,State of of Celifornla—Health and Welfare rc1 Department of Heallf Sety txs <br /> Form Approved OMB No 2050--0039(( by, q30-91) Toxic 9ubelencee Conlrnl Divlen <br /> Sacramento.Calif role <br /> pIbar,@ print or type. (Form designed toAbse on elite 01asswer,typewriter). ... - <br /> UNIFORM HAZA812 19, <br /> R{jj©�Qus I Generator's US EPA ID No. Manifest age I nformalton In the shaded areas <br /> WASTE MAI ttoi Dome nt, of le not required by Federal Inw <br /> CALOOD02 c <br /> S. Generator's Name and M dolif ess' A. Stele Manifest Document Number <br /> ��•. 89682234 <br /> Liincol . <br /> 8203 W. Tracy, CA. ?5378 E. Stale Generators ID <br /> a. OeMrators Phone(JI i )'C,:. '-.r' . .( ,I <br /> yj S. Transporter 1 Company Nam, a B. UB EPA ID Number C. Stets Tranaporter's ID o <br /> Placer TracCOT ScnX -C@ A n [ D. Tp <br /> repe d-e-Phone 916-452-55151 <br /> N <br /> m 1. Transporter 2 company Naim`' S. IIS EPA ID Number E. State Tnnaporter's 10 <br /> p a F. Transporter's Phone <br /> W Designated Facfilly Home'and Site Address 10, US EPA ID Number G. State Facility's ID <br /> <— i Refinery Serp'Ces 1_ <br /> 13331 14. Iiirjimy 33 H. Facility's Phone <br /> Nz PattexsrxL, CA. 05363 C A D J1813111016 71218 800-874-4444 <br /> 12. Containers 13. Total 14. 1. <br /> W9 11 US DOT Description(including Propei Shipping Name,Hazard Class,and 10 Number) Quantity Unit West.Na. <br /> No. Type WitVol <br /> LOU e. - - state ?.41 <br /> rnZ G Rjel Oils Finneate .. EPA/Other <br /> :)o� E OO1TIT o G <br /> 3 E 0. -- --_ State <br /> A EPA/Other <br /> J- <br /> 14 State <br /> $m EPA/Other <br /> w tl. State <br /> W ENVIRONMENTAL HEALTH EPA/Other <br /> WRnnlr i SERVICE <br /> 2 <br /> J. Additional Deacriptionv Int Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O a. b. <br /> Q. 1 Wm <br /> eatei <br /> O <br /> G _ 15. Special Handling Instructions and Additional Information <br /> Z <br /> J <br /> U te. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents or this consignment are fully and accurately described above by proper shipping name <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 /> rational government regulations. <br /> 2 If Idem a large quantity generator.I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree 1 here determined <br /> Q to be economically practicable and that 1 have selected the practicable method of treatment.storage,or disposal currentlyavallable to me which minimizes the <br /> present and future threat to human health and the environment;OR.1f I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the beat waste management method that Is available to me and that I can afford. <br /> WPrintetl/Typed/Name signal Month Day ye r <br /> W <br /> 17 / `./ / ry I <br /> W 17. Transporter 1 Acknowledgement of Receipt of Materiels %- <br /> ZA Primed/Typed Name Signature Month Day ye r <br /> N <br /> S / <br /> P <br /> W O 18. Transporter 2 Ackn wledgement of Receipt of Materiels <br /> TPrintedliypetl Name Signature Month Day v r <br /> U i <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> 120. Facility Owner or Operator Codification of receipt of hazardous materiels covered by this manifest except as noted In Item 19. <br /> y Printad)Typed Name Signature MonfA Day Ye r <br /> DHS son A(t res) Do Not Write Below This Line <br /> EPAe7(ID-22 - 1=FMRAT)R lfli Ip'v <br /> (Rev 9 9e)Previous editions are obsolete. <br /> i <br />