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State of California-Health and Welfare Agency <br /> Form Approved OMB No.205U--0039(Expires 9-30-B Department of Health Services <br /> Toxic Substances Control Division <br /> Plhese print or type. (Form designed/or use on alit itch fypewdter). Sacramento,California <br /> UNIFORM HAZARDOUS - enerato%a US EPA ID No. Manifest 2. Page 1 E,,93r <br /> the shaded areae <br /> WASTE MANIFEST CAC 0 0 0 7 ✓3 4 1 1 2 iD° a "°'3 of 1 d by Federal taw. <br /> 3. Generator's Name and Meiling Address A. State Manifer <br /> HEUBLEIN WINES <br /> 21801 Hwy 120, Eacalon, CA B. 91eteOeseralor'aID- <br /> p oll <br /> 4. Generator's Phone( 209 838-3575 <br /> 6. Trane orter 1 Company Name e. US EPA ID Number C. State Transporter's ID .,iv <br /> - <br /> N N0� CAL 61L CAD 9 8 2 4 1 7 2 5 5 D. Transporter's Phone <br /> R7. Transporter 2 Company Name e. US EPA ID Number E. State Transporter's ID <br /> g I I I I I I I I F. Transporter-!—Phone <br /> A 9. Designated Facility Name and Site Address 10. US EPA ID Number O. Slate Facility's ID <br /> REFINERIES SERVICE CI Ai Di 01813111 Gi di 7121 <br /> qf� 13333 North Hwy. 33 H. Facility's Phone <br /> C0MZ PATTERSON, CA 55363 CAD 0 8 3 1 6 6 7 2 8 900 874-4444C0 NO 12. Containers 13. Total 14. I. <br /> NLL <br /> IT. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> �a <br /> No. Type Wt/Vol <br /> a. Stats <br /> X Z HAZARDOUS WASTE LIQUID N.O.S. T T 223 <br /> inn N ORM-E NA-9109 0 0 1 f 93 G EPA/Othx <br /> 3 E b. <br /> di R State <br /> A <br /> mT <br /> N O EPAIOIher <br /> a R c. <br /> o State <br /> EPA/Other <br /> W d' State <br /> Z <br /> U <br /> EPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above <br /> Z K. Hantlling Codes for Wastes Lleled Above <br /> a <br /> a. b. <br /> TANK BOTTOM WASTE <br /> RINSAT6 C. d. <br /> Zz <br /> 0 <br /> Q15. Special Hantlling Instructions and Additional Information <br /> Z SEE E.R.rx. 31 <br /> APPROPRIATE PROTECTIVE CLOTHING "EMERGENCY CONTACTI 800-332-8710" <br /> J <br /> J <br /> U 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> 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 /> d national government regulations. <br /> V! <br /> ¢ If I 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 1 have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,it l em a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that Is available to me and that I can afford. <br /> Z <br /> Printed/Typed Name Signator <br /> _ Month Day Year <br /> 1 /1 /1 191*7 <br /> w T 77. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> Q A Prinr/Typed Name Signature <br /> N L Month Day Year <br /> U. 9 ,�rl1,r, i? P/11: rid' �7r ;% �, <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> to R Printed/Typed Name <br /> O E Signature Month Day Year <br /> 2 <br /> 19, Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in hem 19. <br /> T <br /> y Printed/Typed Name Signature <br /> Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9.88)Previous eciltlons are obsolete. <br />