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State of Califond, Health and Welfare Agency See Instructions on Bao of Page 6 Department of Health Services <br /> Form,Approved OMB No.2050-0039(Expires 9-30-r Toxic Substances Control Division <br /> Rease prinCor type. Form designed for use on ellte�p)tch typewriter). and Front of P` 7 Sacramento.California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Mandeat 2. Page t <br /> Document No. Information in the shaded areas <br /> WASTE MANIFEST d 41 of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address - A."State Manifest Document Number <br /> E).Yon Co>IRpany U S A 910191506, <br /> ���y(� (s7 }p� B. State Generator's ID <br /> a:`GS7frMatdf'S$I�olfs[' . Suite 1250 Concor3, CA 94520 <br /> b 5. Transporter 1 Company Name S. US EPA ID Number C. State Transporter's ID <br /> 102077 <br /> n -D. Tranaporter's Phone 0 A 11 Ex EI <br /> N <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> 8 F. Transportses Phone <br /> as 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> a Refinery Serkice <br /> ° 1333 HWY 33 Patterson, CA 95363 H. Facility's Phone <br /> C05CD 300-874-4444 <br /> cc12. Conte hers 13. Total 14. 1, <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class.and ID Number) Quantity Unit Waste No <br /> 'LOW <br /> __._... No. Type Wt/Vol <br /> State <br /> �Z �a',��� ) <br /> E Non•-RERA I-9Z Waste- Rinsfabe -.� - - EPA/Other <br /> t-_3 N r_. . - t.-.. _ _ - <br /> E" b. _... a - - ` .t State <br /> CSi vy. .R.. <br /> A.. <br /> 0 T <br /> 'EPA/Other <br /> 4 O <br /> N R c. - state <br /> V <br /> 8 <br /> m <br /> _ EPAransr <br /> ¢ <br /> w d. State <br /> Z <br /> z <br /> W <br /> U EPA/Other <br /> W <br /> ZJ. Additional Descriptions for Materials Listed Above K. Handling Codes for Weatae Noted Above <br /> O e. It. <br /> N <br /> W <br /> a o a. <br /> J <br /> Q <br /> Z <br /> O <br /> H 15, Spacial Handling Instructions and Additional Information <br /> Z <br /> Z <br /> W <br /> t <br /> 5ITe Loc-A4i'e, - Cj0411s ckTt-,-j <br /> U <br /> is. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J 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 /> N national government regulations. <br /> -M _ _It 1 am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O to Seeconomically practicable-lied that INave'selebt6d The prab9cable method df trestmentl stcrage;or disposal currently available to me which minimize,the <br /> present and future threat to human health and the environment:OR,if 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 /> Z <br /> U P I d/P'nted/Typed Name i nature Month Day Year <br /> w feta y. J ,.)L rllxJr.l <br /> C :11 1h <br /> wT I?. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> Z A Print d/Typed Name Signature Month Day Year <br /> N <br /> O p 'eer'_I <br /> w O 18. ranap iter Ackn wledgement of Receipt of Materials <br /> UR Printed/Typed Name signature - Month Day Year <br /> E <br /> Z_ l� <br /> 19. Discrepancy Indication Space m r ' <br /> < .. NOON ZN <br /> I20. Facility Owner or Operator C&r13I%ff.fl,of r.cIIipiirdous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y I Printed/Typed Neme � c �\v" Signature Month Day Year <br /> DHS 8022 A Do Not Write Below This Line <br /> EPA 8700-22 -' <br /> (Rev.6-89)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />