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State of Callforme�eellh and Warfare Agency Deportment Of Hsegft <br /> Form Approved ONE No.2050.•-0036(Expires 9.30-0 Sas Instructlane P k of Page 6 Toxic Substances Go a <br /> v <br /> Lode `C�45�4Z <br /> a. lora 209) 369-9631 <br /> e 5. Transporter 1 Conpffy,tams 8. US EPA ID Number •, Cg,,9atsT <br /> H & H Ship Service Carpany IC A ID 10 10 14 17 1Tw.±P9!Isa' 4t 5 54.. <br /> 7. Transporter 2 Conpaay Name S. US EPA ID Number <br /> 9_Dsai6pated Facility Name and Sh,Addrau 10. US.EPA IO Number i mf * o a ry'.Gxifir:'. <br /> J H 6 H Ship Service Company <br /> Street <br /> �� 220'Chin' Bas'rn Rpppa e <br /> <_ Sari Franc fS , CA 94107 f ; i •t�a`v+ F, a <br /> z 0 10 10 14 17 17 IT 11 16 t8 3` S1K3-483 ' <br /> "I - <br /> r-6 k4�... .T .. - 12. Containers -. 1& Total 14 <br /> ti. US DOT Oea<yiplbn Oncludkp per ProShippeq Name,Hazard Clam.and ID Nwnber) Ouatily, Unf <br /> C\ja- tri. :Type WI/Vol <br /> CV= WASTE BOTY TANK, �671BLE LIQJID NS <br /> 0 p NA 1993 001 TP0 00 01 G < 2 <br /> Oil l #f'. ':tea✓.r' <br /> OP T <br /> R C. Slslf y,, <br /> m �EPArgMr :... <br /> w d. SaM z-•r <br /> W <br /> � EPuom.r, <br /> W .:..ac <br /> rn L Addtbnal DascdpUb ter L4aterisis Uwtl Above. ".d K,Handling Codes for Wastes Luted Abmf , <br /> ll�,BtN(ER (1[l STOR/!CE TANG WITH >a t 01 kta <br /> W <br /> i AE'E'FdDf t TW , X200) GALLONS RES I D JALS0LJ DS <br /> R�tA1HT r u}tc4etl <br /> < z <br /> Hrf[V( ANC. a i2 <br /> a <br /> 15. Special instructions end AdtlrflaW information TANG MOVAL SITE: 550 North Sacramento Street <br /> Z <br /> PRL7TE("TIVE MAR AS REQUIRED. Lodi , CaI i fornia <br /> J <br /> J <br /> < 18. <br /> U <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 ere classified.packed.marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> a national gonum ont regulations. <br /> N <br /> it I em•large quantity pr generator.a I that <br /> that I have a program in cable to reduce the volume for toxicity of waste generated athe degree have determined <br /> p pr be et and <br /> hreatl to hu ern teat I have he sora the practicable it I method of treatment storage,or a disposal ea good faih available to me which minimizes ast Me <br /> Y <br /> present and fume threat to blames health 911tl ins ernironmenU OR,a I em a smell quantity generatoq I have made a good lank eaprt to minimize my waste <br /> V generation and select the best waste management rnMhod that is available to mea�o that I can afford,__,,;, <br /> 2 <br /> ,W' Fruits /Typed NameSigna Month Day year <br /> w <br /> ED W I SNER 10 !Ll 12 181819 <br /> wT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> 2 R <br /> < A Printed/Typed Name Sionatura Month Day Year <br /> o "s ESTEBAN M. PERI VM J 10 14 12 1818 Y. <br /> P <br /> O 18. Transporter 2 Aundwiedgement of Receipt of Materials <br /> w <br /> w <br /> < R Primed I Typed Name Signature Month Day Year <br /> V <br /> 2 E <br /> 19. Olsereoancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner Or Operator CwhArAtion of receipt of hazardous materials covered by this mandeat except an noted m 0. 19. <br /> T <br /> Y Pant Name &gnatura Month Day Year <br /> IF <br /> DNS 8022 A(1/88) Do Not Write Below 2021A, <br /> EPA 9700-22 W6 SFNDS THIS COPY TO DOHS WITHIN 30 W <br /> (Rev.X88)Previous editions we obsolete. <br /> To: P.0 <br /> . Box 3000, Socramemo, CA 95812 <br />