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Stale of California—Health and Welfare Agency Department of Realm <br /> S.rwc.n <br /> ' form Approved OMB'o.2050-0039(Feel 3080) SAG• ioym Subsuncss Control Division' I Ple ge print ort e. (Form deal red toy a elle(f2 itch f lwnfeH. Sacramento.Calilornia <br /> UNIFORM HAZARDOUS 11. Generator's US EPA 0 No. Nanl 2, Page 1 Information in the shaded areae <br /> WASTE MANIFEST1L d toAlf3 Docamem No.I 'of is not required by Federal law. <br /> 3. Generator's Name and Mellkp Address A. Slate Merriest Doeumad Number <br /> ' 00THP_t2N ACIFIG 11 (T��;P�(R�iF�f1oN] Co . 876210 <br /> t KE <br /> 1L ?L� y �. 111u I�a�/ S. Slat.Generator aD <br /> � k W: <br /> ' 5. Trmaporter`f Compury Nam. e. US EPA ID N~ C;State Transport•es 10 <br /> Wo IIP /p 2 D: TransportiWe Pha <br /> I n• <br /> 7. Transporter 2 Comparry,Nacos 9. US EPA ID Number E. Stat.Traasperta-6 b <br /> • - a ' - F. Tranepor ey's Plains it -.�.O,j.i`Mill, <br /> a. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's 0 .. t /} <br /> G1050N OIL I _ R>cp�11NIIJ6Y Q hh A �: / • <br /> r.N D ,b* c o rA mF,KU A . H Facilely s Phone <br /> .Q (14 <br /> : <br /> ' 12. Container 13. Total r le :tr <br /> f 1. US DOT Desadpti a(Including Proper Shipping Name.Hazard Gass,and ID Number) Quantity Und <br /> No. Type W11410 . .q_!i <br /> ' c e.KJA&Tle 6- <br /> QASOL� NS�DIr-5, - st..4 �: f . <br /> 41:11 <br /> N. '1CALIrV1Z A .:'R6HU1,AVI)S o EPA/Oe•r <br /> E, IsUN �3 isut <br /> ' 3 A <br /> T t EYA/Other -: <br /> d is <br /> pC. State,!.,1bL�t, _t . <br /> :;t <br /> d. <br /> slag.}. d <br /> EPA/ - <br /> r1 <br /> evlpmu ror�Mae.rW.Uated Alava � k NUMWg(iO4g!ray V/ssbr Lbt <br /> Atrev <br /> 15, Special Handling Instructions and Additional Information <br /> Gt✓oUES) C6q.Ci ltiS, f1 QD PROT�.C,TJUL OMk C1Ak �71G QM , <br /> r o39 3 <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this e,assignment,ars fully and accurately described above by proper shipping <br /> ...a and are classified packed,,marked and labeled and are in all respects in proper condition for transport by highway according to applicable <br /> at atlauI andnational pavemmeM fequlelions.. r - - <br /> t t n .ram l : .3' "Ei•. _ <br /> N 1'Ni•Tarps glimtity-generetor;.l drt1M.thif I have a propiam n place to reduce the volume and toxicity of waste generated to tae degree 3 luvei <br /> det'armuted lo.be' laically practicable sAlf that r have selected the practicable method of treatment, storage,or disposal currently evadable to <br /> m6`whleIf minimize+the present and tat"threat to human health and the environment'OR, if I am a small quantity generator,I have made a good <br /> } faith,effort to commix•my waste Ostentation and select the beat waste management method that is available to me and that I can allord. <br /> } _ Primed/Typal Name ' T _Y Siaruat : I, Mona Dry year <br /> fes' <br /> f F fr Tramsparter 1 AcinarelotAgenigood alilecapk or Materials <br /> I A Prim Typed Nemo 1 5 psster Month Day Year <br /> 41"1!7, r <br /> } Q 1&. nn er.3 ACknowNAgemem of R.catpt of Maede4 .. rT�: - <br /> ' R Printed/Typed Name Signature Month Day Year <br /> I <br /> A 19 Discrepancy Mdaetion Space <br /> 41 <br /> F. # 20.;Facilar,Peneraofnparalor Certification of racei t of hazardous materials covered by this manifest ucept as noted m nam 19. f y -q ;(:✓.. <br /> Ds,to Y.ar <br /> . a PrmtedlrT ed m. ' ' .. f i� Sgnalw•,.,y f i ` MmfAt� pprr <br /> �•T [ . M..Pv elle' w:+cisT�J1• I Yn:nrLY ,}ygdl /ia iuv:;.f, y 1e• ..JJ p. nom.),', (y I !i' .: <br /> ONS i022i (I)87T ' �z E i, v sd f u.1 <br /> EPA V, E Yellow TSDF SENDS THIS COPY TO GENERAT RHIN 90 DAYS INSTRUCTIONS ON THE BACK t <br /> t ,.t F4rl <br /> ' (BeBP e`roeeditions are Obsolete- on rni x`*T2' R r,. <br /> '�rt`�"n }.•��,. F.. i 'L lir s .+ t .,Y 1. <br /> nn i Tyr N-1TInNM PF¢Pnu;F CFNTER 1-800-d2A 8802: WITHIN CALIFORNIA CALL' 800852:7550)_; <br />