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13 <br />O v T JNmanl of VMsbh Sarvlpe <br />81ate o1 CWlcnia--lleeKh and welfare Agency 0-7011Y cpn In-,ir rct%DnF on 9?r Of Page 6 Toxic Substances Control Division <br />Fai Approved OMS No. 2050-0039 (Expires 9-3091) Sacramento, California <br />anis Front Oi PaOE T <br />PNYN <br />perm or type. er. aeargrnw <br />Manifest <br />r <br />UNIFORM HAZARDOUS <br />Generator's US FPA ID No. <br />Document No. <br />rp n <br />o <br />Yha sheded areas <br />- <br />'+nbF feu red by Federal aw. <br />WASTE MANIFEST <br />A a o 0 i <br />1/I'' <br />9. Gep.M�rator's Nam and Mailing Address / <br />A. Stab Manifest D u'}1nerL��1 <br />8 1 <br />N4ylnbar[� <br />J J 6 9 <br />B. State Generator's ID <br />e. Geon./ <br />6. Transporter 1 Company Nam e. US EPA to Number <br />C. State Transporters ID <br />D. Trem ponnsPhone _ <br />DILLARD TRUCKING i C i Ai D 1 91 81 11 61 91 21 81 01 9 <br />T. Transporter 2 Caepatty Name S. US EPA to Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />Erickson, Inc. <br />255 Parr Blvd. <br />H. Facility's Phone <br />Richmond. Ca. 94801 <br />1 C1 Al DI 0 4 <br />— <br />12. Conb9mra <br />13. Total <br />ta. <br />L <br />11. US DOT Description (Including Proper Shipping Nome, Hazard Class, and 10 Number) <br />Quantity <br />Unit <br />WOb No. <br />No. Type <br />Wtivol <br />a. <br />512 <br />G <br />Waste Empty Storage Tank <br />EPA/( <br />E <br />N <br />California Regulated Waste Only <br />O O 1 <br />T P <br />0 0 51 5 0 <br />P; <br />None <br />E <br />e. <br />Stab <br />R <br />EPA/Ot1W <br />A <br />T <br />O <br />R <br />c <br />State <br />EPA/Otlter <br />it. <br />Stab <br />EPA/Odww <br />J. Additional Descriptions for Materials Listed Above <br />K. "ancient Codes for <br />Wastes Listed Above <br />a. O 1 <br />b. <br />Empty Waste oil tank, x2073 iced With 15 lbS. <br />C. <br />d. <br />dry ice <br />15. Special Handling Instructions and Additional Information <br />18. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described some 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 />national government regulations. <br />If I am a large quantity generator, I canny that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to rite which mi ilmizaa the <br />present and future threat to human health and the environment: OR, it I am a small quantity generator, I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Ty ed Neme <br />Si Month Day Year <br />c-:� &>lrloCs <br />16 10 1? <br />T <br />R <br />Il, Transporter I Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name / <br />Signature MaIM Day Year <br />N <br />S <br />PO <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Sgnature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered b hi manifest except as noted in Wit <br />T <br />y <br />Pdnte Ty ed Name <br />Signatur Maim Day Year <br />Af '?'R N h Olt / <br />& s �" �f�101811 1O <br />DHS 5022 A(1/ee) / Do Not Write Below This Line,' <br />EPA 5700-22 f:' TS 6 SFNDS THIV-0PY ?O DOHS WITH'M <br />(Bev. 5-55) Previous editions are obsolete. <br />. 1 FO. 8e-, 5000: Sgcgmenfo, !:P. 9521:: <br />