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of ColRarnW-Health and Welfare Agency Department of Health Services <br />Approved OMB No.2050-OD39(Expres 9-3091) `�. S" Instructions on back of pagO Toxic Substances Control Pogrom <br />e print as typefpm designed for use on e0fe (12 -pitch typewriter) Sacramento. California <br />1 <br />UNIFORM HAZARDOUS <br />1.Generator's US EPA ID No. Mnnlml Document No. 2. Pagel <br />IMomnlion h the shaded aea <br />WASTE MANIFEST <br />CIAIC10,010,6,5,3,21916 01 0, 01 0, i o 1 <br />bwtre 4edbyFededkxw <br />3. Generotons None and Moiling Address <br />(coTEGZr L.f{T1i,�QL <br />'A State Manifest Document Numhwr <br />9 % 8 Q 41 <br />1856 N. BroadT-ray <br />,sate . or, <br />' 1. , I, <br />a Generator. Phane(209 ) 465-3609 Stockton, CA 95205 <br />5. Transporter I Company Name <br />0. Us EPA ID Number <br />C. Stale Trorcwn. s ID 6 0 <br />Falcon Energy Associates <br />C IA I D 19 18 12 15 12 16 18 15 17 <br />D, Imnsppnele Phone - <br />7. Tromporter2 Company Name <br />B. US EPA IDN umber <br />E. Stale. Tronporters ID <br />F. Tetra v, Rnn" <br />I I I I I I I t I I I <br />9 Dost mated Facility Nome and SBe Address <br />10. US EPA ID Number <br />G. State Faci!Ns ID <br />PRC - Refineries Services <br />I I I I <br />13331 HWY 33 <br />C, A, D10,8t31116t6,712,8 <br />H. i-uc'1 Iy x PT2'09) 892-6742 <br />12. Containers <br />13 lotal <br />14. Una <br />11. US DOT Description (Including Roper Shippirg Name. hlozord Ckm, aro IO Number) <br />Qua,lrry <br />Wt/Vol <br />I. Wns!e Number <br />NO. <br />i <br />O. <br />NON RCRA Hazardous Waste Liquid, N.O.S. <br />Store <br />133/134 <br />E <br />(rater, gasoline & diesel) <br />010 11 <br />TIT <br />,b, S Q <br />G <br />'ff RCRA <br />F <br />D. <br />'rl <br />Stene <br />Wari-irs CnmhTg+ihta T <br />221 <br />R <br />g <br />q <br />01 0 11 <br />T T <br />I I 1 I <br />G <br />non-rcra <br />T <br />c <br />Slate <br />R <br />I I <br />I r <br />I I I I <br />EPA/Cine! <br />a <br />.scare <br />I I <br />I <br />I I I I <br />*, <br />J. AdI Cuscrptior» for Materials I"eted Above <br />K. Hoodl,ng <br />Codes for Wastes L ed Above <br />a. Tans Rinsate <br />a <br />b <br />a <br />15. Special Handling Instructions and Additional Inlormatbn <br />Emergency Response Falcon Energy Associates (209) 463-7108 <br />10. GENERA70RI CER71FCATION: I hereby decbre that the contents of the consignment are fusty and occumley dexcribed above by proper shipping roma and are classified, <br />packed. marked. anal labeled, and are In ON respects In proper condition for transport oy highway according to applicable Intematksnal and naliond goyemmenl regulon m . <br />K I an a ksge auantlly generator. I certify that I hove a program n place to reduce the volare and IoxicM of waste generated to the degree I hove determined to be <br />econonsicOFy practicoble and that I have selected the practicable method of treatment, doroge. or disposal currently avalloble to me which mInlnkos the present on3 future <br />threat to human heath and the e v ronmert; OR, M I am a smolt qupntey generclor. I have made a goad fallh effort to minimize mr, waste generation and select the best waste <br />management method that's ovo,bbl9 to me and that I can afford. <br />Printedilyped Nnme <br />Sign t <br />Monet COY yeas <br />T <br />17. anporter 1 Acknowiedgilment of Receipt of Materials <br />R <br />PMted/Iyped Name <br />n e <br />Monet tea <br />KehN �� <br />i <br />tI•� <br />P <br />0.�Ll <br />1 ) i�l�/iV`j ...r. <br />IO. Iranporter2 Ack Nment of Receipt or Matorloe <br />R <br />PMted lyped Nome <br />Sure <br />Manm Day tea <br />T <br />R <br />F <br />19. Discrepancy Indication Spoce <br />A <br />ci.�_ 1Vb <br />I <br />L <br />1 <br />20. Facility Owner or operator Certification of receipt of hazardous materials covered by the manifest except as noted In item 19. <br />T <br />Printed/typed Nome <br />SignaMe <br />Monet Day, roar <br />V <br />I <br />DO NOT WRITE BELOW THIS LINE. <br />1022A(12190) A`p'.zr' S-rStIZENi;; C:)PY R.i vI 1SA IT, I"Y30DAYi <br />oW-22 Tc O. iy,- 30W, ;acranento, CA 9;111'2 <br />D <br />17' <br />