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State Of COINOMIJ–Realm and welfare Agency <br /> See Instructions on Department of Health services <br /> Please Print or bocv.' l page 6. Toxic Substances Control Program <br /> W type. Form designed for use on afro(12pHch rypewrlte0. 9 <br /> Sacrannento.CdlforrYo <br /> UNIFORM HAZARDOUS 1.Generators US EPA ID o. Mantled Document No. ZPageI Information in the shaded a,= <br /> WASTE MANIFEST I a - 'i I i I I I qr a net required by Federal k <br /> 3. aVwx ltars ^ Ma^n s A Sts o lints fast L]ticumenf Number. <br /> Sr r4f- 4r We <br /> O.SiO! no(ptolY IO <br /> a Gereratoh Phone( > 6 <br /> Transporter <br /> 1 Compary Nome I i <br /> 6.Ib EPA ID Number C.State'ronsporfers D. <br /> REFINERIES SERVICE (PRC) C p P 9 8 1 A 0 6 2 A o; la^ > ersP qn 20 9 - 70 <br /> 7.Transporter 2 Company Name 5.115 EPA ID Number E:Slat. ID <br /> I <br /> 9.Designated Facility Name and Site Address 10.l5 EPA ID Number ID <br /> REFINERIES SERIVCE (PRC) `fe xId'S <br /> N V I I <br /> 13331 N HWY 33 PATTERSON CA CIAIDI 0I 8I 3I 1I 6I 6I 7I 2I 8 '(k097"'M-8670 <br /> 11.US DOT Description(Including Roper Shipping Name.Hated Class,and ID Number) 12.Containers 13.Iotp1 la.Un t <br /> JNo. 7 e Q✓Sni M1Vol I Wade Number <br /> G <br /> a NOW C Za or/S o S STat <br /> (,,�v <br /> Z N 1 01 , {71 1 01 A tear <br /> Q <br /> !-�Cn b. <br /> Ln S ECO ate <br /> R <br /> MU A <br /> T c. <br /> (�= 0 state <br /> /r" 3 R EeAratb, <br /> V ry <br /> O E <br /> 0 &pn <br /> Q <br /> yN � <br /> J AtkLtlond Descri;:I gfIX Alaforials.istc+cJ Above KHprdhng CgCaf far Wastos.Latod Atone <br /> c b. <br /> z fI <br /> w <br /> U IS.SpociplHaruiling lnsiructans anuli AddRanal lntormption — <br /> z 24 HR. EMERGENCY CONTACT: 800-874-4444 <br /> Q- 24 HR: EMERGENCY RESPONSE: CHEM TEL INC. 800-255-3924 <br /> c APPROPRIATE PROTECTIVE CLOTHING & RESPIRATOR <br /> J <br /> Z16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment ore fully and accurately described above by proper shipping name re and aClassified, <br /> O packed,masked.and labeled.and are In all respects In properconcRbn fortransport by highv oy according to applicable Intemational and rnationol povemment reguiotiom <br /> .– n I an a large quantity gorerator,I codify that I have a program in place to reduce the volume and toxic'M of Waste <br /> Q generated to the degree I have pretenm4»d to be <br /> Z economically PractkaDle and that I have selected the practicable rtneftwtl of treatment,tloroge,or tleFwsd currently available tome which minimizes the present and future <br /> w threat to human health and the environment;OR,IT I am a mal quantlfy,generator,I have Made a good faith effort to minimm my waste generation and select the best waste <br /> management method the Is available to me and that I can afford, <br /> J <br /> Q <br /> Printed/Typed totl/Typetl Nome Sigure Monm Tby yea <br /> U <br /> J <br /> rn T .Transporter 1 Acknev e <br /> c Trtlgerrent of Receipt a Materials <br /> O AR Pnnletlfsypod None Signature Monm Qry year <br /> U N <br /> Z s <br /> w Is P161 I <br /> I I I <br /> w 0 78.tree ter2 Acknowledgement of Receiptof Materiae <br /> R Printed/Typed Nome Signature Monm Dpy year <br /> O E <br /> R <br /> QF 19.Discrepancy mdicaion Space I I <br /> U A <br /> Z C <br /> I <br /> lea• <br /> 20.Facility Owner or Operator Certification of receipt of hmartlou matemlak coveretl by the mgnlfest excepts noletl In Rom 19. <br /> T Printedfryped NomeSignature Monm Day year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. ` <br /> DHS e022A(12!90) Blue-T ENERATOR SENDS THIS COPY TO DI-IS WITHIN 30 DAYS, <br /> EPA 5700-22 TO: P.O.Box 400.Sacramento.CA 95812-0400 <br />