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State of Col'ifornia—Environmental Protection Agency <br /> r' f ft Approved OMB No.2050-0039{Expires 9-30.99) See In3tructions an back )C a 6. <br /> Please print or type. Form designed for use on elite(12-pi+,.,..,,oewr;fer. Department of Toxic Substances Control <br /> + Sacramento,California <br /> UNIFORM HAZARDOUS 1- Generator's US EPA ID No. Man5tato <br /> o. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST i `. F s ��' �' is not required by Federal law. <br /> [ r' of3. Generator's Name and Meil'sng Address 1 , State Manifest Document Number22700848 <br /> . 1 [ ir. I State Generafar's ID4. Generator's Phonen1r04 5. Transporter 1 Company Name6. US EPA!DNumber 5tato Transporters.lD[Reserved.} <br /> r� €i:FeICAIN 1,+�,Al_LLY WA3i L Oa` A L G ii ij z? +�.. Traoapartars Phare 7, Transporter 2 Company Name B. US EPA!D NumberState Transporters ID Reseco UTransporw's Phoneky.bite S `t A es . 10. US EPA ID Number . 51cive nywa o 0 1 -0 0 a I <br /> ©z 5-300 CLAUS ROAD <br /> H. Facility Phe e <br /> �o RIVEEN13ANK. CA 95367 A L � [3 11111 '91G 13 16 ��� -i SSR <br /> IN 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number[ 12. Containers 13. Total 14. Unit <br /> No. 7 Quantity Wt/vol I, Waste Number <br /> Z a. NON-RCRA I"AZARQO1..3S WASTE UOUID state 22-12 <br /> 3 G (OILY WAS!i ER €3[ 0 1 7 i <br /> 5A/01her <br /> ON b' state <br /> co E ` <br /> -4t R r EPA/00w <br /> C14 A <br /> a T `' state <br /> wo O ` <br /> R EPA/Other <br /> ae <br /> Lu d State <br /> Z <br /> w <br /> U EPA/Other <br /> u.s <br /> in J. Additional Descriptions for Materials 1r4ed Above K. Handling Godes far Wastes listed Above <br /> o OILY WAITER b. <br /> w <br /> c. d. <br /> J <br /> Q <br /> Z <br /> 0 15. Special Handling Instructions and Additionai Information <br /> Z 'MERC-C-.NCY PHOt4E- 209-667-8857 <br /> uj <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> marked,and labeled,and are in all respects in proper condition For transport y highway according to applicable international and nafional government regulations. <br /> J <br /> -� IF f am a large quantity generator,I certify that I have a proggram in place to reduce the volume and toxiciy of waste generated to the degree 1 have determined to be economically <br /> practicable and that I have selected the Practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future thfeat to human health <br /> and the environment;OR,if I am a sma I quantity generator,I have made o goad faith effort to minimize my waste generation and select the best waste management method that is <br /> ly- available to me and that I can afford. <br /> O <br /> �• Printed/Typed Name 5ignaty a Month Day Year <br /> U r :1:31 <br /> f 1 <br /> Z3 R 17. Transporter 1 Acknowledgement of Recei t of Materials <�r <br /> w Il Printed/Typed NameSig¢viura. - Month Day Year <br /> wP a`. ".�r''�,t` _ `ter Cti <br /> si 0 16. Transporter 2 Acknowleciement of Repbi t aF Materials <br /> TPrinted/Typal Noma Signature Ma nth Day Year <br /> LuE <br /> vn p <br /> U19, Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> f1 20. Facility Owner or Operator Certification of receipt of hazardaus materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A {1/94) <br /> EPA 87700-22 Yellow: GENERATOR RETAINS <br /> -- • <br />