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I <br />0U of Approved <br />No <br />land Welter•Apency <br />ires <br />Form Approved OMB No. 2080039 (Espiree 9-30-B t) <br />e <br />r" D•partmenl es Control <br />Sanies <br />I <br />Toxic. <br />oxk Bub Sacramento, <br />mento, CalifDilotion <br />rnia ' 8aaam•nlo. lllnla <br />Aue print <br />or type. (Form designed for use on ellle (12 pit cn fYpewrded <br />UNIFORM HAZARDOUS 1 Generator'- US EPA ID No. t <br />Documanl No.. <br />- <br />2. Paget information h int Mad•O •ens <br />curren <br />of U not squired by Federal law <br />WASTE MANIFEST <br />3. Generator's Name and Mailing Address <br />A. 8tata Manib�t Docum•rd Number <br />8 9492889 <br />STIMIS a6%IT SllDP <br />B. state G"watore iD <br />275 Grant I ne RUad <br />Ira cY A 9"791 r <br />entre aFa ane836-75117 <br />ti. Transporter 1 Company Name S. US EPA ID Number <br />C. State Tronsporlw-8 D <br />0. Transporter's Phone OHM <br />8 <br />7. Transporter 2 Company Name e U A um mer <br />E. Stale TnNporter'a D <br />F. Transporlw's Poona <br />9. Designated Facility Name and Site Address t0. US EPA ID Number <br />G. Slate Feclgty's ID <br />H 6 H Sh I p Se ry I ce (k)TTT)any <br />220 ((Tina bdsin Street <br />n. F t <br />Son Francisco, CA 94497 <br />11. US DOT Description (Including Proper Shipping Name, Hazard Claes" and ID Number) <br />12. on alners <br />No. Type <br />T ta <br />Quantity <br />Unit <br />WI/Vol <br />t. <br />Waste No, <br />Slab . <br />a. <br />FES I TIE WASTE OIL TN4( <br />fij <br />�2 s o <br />PjFA-1OfiWva­ <br />g <br />E <br />[CAL.I R* NIA (TIL.Y IEi"IAATED WASTE) <br />N <br />Wom <br />E <br />b. <br />R <br />A <br />EPA/ WNr <br />T <br />0 <br />seal* <br />R <br />C. <br />FPA/Other <br />d. <br />slate <br />EPA/Other <br />Jat . ddRl Dostrlptime for Materiels Listed Above 1 <br />K. Handling Codes lot West" <br />Listed Above <br />�. .,.. <br />PlhPED CUr $00 gal Ion tank lest contalning waste oil <br />tank )nert*d with dry Ice for transport. <br />d. <br />Vice. <br />16. Special Handling Instructions and Additional Information <br />AFK""RIATE ff"l-ECTIVE CLOTHIFd:; Ml) FESPIRATUR. E,P,� 05 1999 <br />to ENVIRON��� <br />GENERATOR'S CERTIFICATION: I hereby declare That the contents of fins consignment are fully and accurately dsecribe gye� : ons <br />an <br />and are classified, packed, marked. and labeled o end are In all respects in proper condition for transport by highway ecc• boil and <br />national government regulations. <br />h I am a large quantity general«, 1 certify that I have • program in place to reduce the volume end toxicity of waste generated to the degree I have determined <br />to be economically practicable and that l have selected the practicable method of treatment, storage. or disposal currently ays6abN to me which minimlzsa IM <br />present and fulurs threat to human health and the environment: OR, It I am a small quentil .generator, I have made s good faith •Rayl to minimlz• my osis <br />penarMon and select the beet resale management method that Is available to me and!h,V I can afford. r <br />PrbdeO/T •d Name <br />Signature Month Day Year <br />T <br />17' Transporter 1 Acknowledgement of Receipt o1 Materials / <br />R <br />APrinted/Typed <br />Name <br />BlgnaI Month Day Year <br />N <br />v <br />(�IkL" VAURL J <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Motorists <br />T <br />Printed/Typed Name <br />Signature - Month Day Year <br />E <br />19. Discrepancy Indicatbn Spree <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. FaclIRy Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Nam 19. <br />y <br />Primed/Typed Name <br />Signature Monts Oil, year <br />66022 A (1/88) <br />1 -- <br />870022 <br />n.9 88) Prevlous editions are obsolete. <br />Do Not Write Below This Line <br />YELLOW: GENERATOR RETAINS <br />