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+• •.W1 . vrn11".81 nandW,ItareAgency Department of Health Services <br /> Toxic Substances Control Division <br /> Sacramento,California <br /> Please print or type. (Form designed for use on elite I rch <br /> Itypewriter.l -= I I �[ 1j;'� j% <br /> UNIFORM HAZARDOUS enerato(s o. anlest ape normanonmtheshade areas <br /> iNASTE MANIFEST CAC 0000 19404 Document No. of a not required by Foder 3 <br /> 3. aw. <br /> enerESC2loneUnifildngChooleDistrict Atgle 4prUsil PoSyment Number <br /> 1520 Yosemite Avenue 43W619 - <br /> bt. anerettxs <br /> a. cenerQFP)A" Fa 9532 209-838-3591IllSRNUe 28-6110 <br /> 5. renom'sr ompany Name U 1 umbar tab Transporter's _"I t /, .i <br /> 8980 <br /> Tom's Barrel Co. CAT .00061121.0 . . . ransportwa Phone <br /> 7. ransporter mpany ama US EPA ID Number E.Stato ransporter's <br /> . ransporter s Phone <br /> 9. Designated acility ems and Site Address US EPA ID Numbertate acillty'a 10 <br /> H 8 H Shlpservice Co 8-38-001-78 <br /> 220 China Basin H.Facility's one <br /> San Francisco, Ca CAD 0041711.68 415-543-4833 <br /> 11.US DOT Description(Including Proper Shipping Name, Hazard Clas; and/D Number 12.Containers 1 <br /> Total Unni t <br /> E "' Empty 500 gal Tank puanti Waste No. <br /> R i TP 200 P D 001 <br /> R <br /> . 14 <br /> b. &Pty 500 gal Tank01 TP 200 P D 001 <br /> 0 <br /> C. <br /> d. <br /> atarfe t1atW _ K.Handling Codes for Wastes Usted-Empty bas Jenk r 8-Empty Diesel Tank <br /> 10 lbs d�tlC r 10 lbs, dry ce <br /> f ice` ay <br /> pecle and ing nauuttions endAdditional Information <br /> 16.GENERATOR S CERTIFICATION:Ideclare that the contentso this consipnmerK are ully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> transport by highway S=rding 1.applicable international and national governmental regulations. <br /> Printed/Typed NameDate <br /> Signature Month By ye r <br /> Mark Hoover <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Typed Name Signature <br /> N g Month Day Year <br /> a Howard EsliCk ; , �, 7 <br /> 0 1B.Transporter 2 Acknowledgement or Receipt of Materials Date <br /> R <br /> T Printed/Typed Name Signature <br /> E Month Day Year <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> T20,Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except in <br /> v Item cept as n <br /> 9. /! _ <br /> Date <br /> Print yp ignaluranth Day ser <br /> DHS 8022 A(7/86) Green: VIER RETAINS <br /> I EPA a 700 22) <br /> M 8,611 <br />