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State of Celilernie—EnvironmaMal Protection Agency <br /> Form Approved OMB Ne.20500039(Expires 9-3091( See Instructions on back a$ page 6. Department of Toxic Subsnmxm Control <br /> Phew print ec type. Fem dmlg^ed for u.on elite(12yia writer. Sacrlil <br /> amemo,Caomia <br /> UNIFORM HAZARDOUS " Generators US EPA ID No. Mariless Documa. 2. Page 1 Information in the shaded amen <br /> WASTE MANIFEST CAD 014131.2171 41318101 3 1 1 10 7 1() of 1is net required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document N..nU <br /> s. n TERESI TRUCKING J <br /> us P. 0. Box 1270, Lodi , CA 95241-1270 a Stet,cen,ra err ID ' <br /> (meqA. Generale,'s Phone (201 368-2472 <br /> d 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID .., 4,. ✓ <br /> CP NOR CAL OIL C A 0 9 U 2 4 1 7 2 5 5 D' Tran,Pcrn,,,phe"° <br /> (209) 667-6692'.. <br /> 7. Transporter 2 Company Name 8. US EPA ID Number ':State Transporter's ID <br /> Q <br /> V }dnsperter's Phone <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number to Facility's ID s1 <br /> REFINERIES SERVICE <br /> c yi <br /> O S 13331 N. Hwy 33 <br /> nty s phone <br /> Pattiargein, CA 991611 CAD08316f, 728 (fl00) II74 <br /> Containers 13. Total 11. Unit <br /> co Z 11. US DOT Description(Including Proper Shipping Name,Hazard Class, ID Number ss, ) NNoo. T W Wt/Vol �ls'aste Number <br /> 00 t- a'NON-RCRA HAZARDOUS WASTE LIQUID irate 223 <br /> N <br /> I �r a (WATER & OIL) 0 0 1 7 i 7 0 0 1 5 0 G FPA/Other <br /> o N b. state <br /> R 'EPA/OMer 7 <br /> Tc, State : <br /> O <br /> R EPA/Other id <br /> I cz: <br /> Zd. Sear, <br /> w <br /> U EPA/Other <br /> i <br /> N � <br /> PPq <br /> g , TANK BOTTOM WASTE K. Ndddcnp eades tar wa,tes Lisr,d Ab <br /> a. b. �I <br /> RINSATE <br /> J <br /> c. d <br /> Q15. Special Handling Instructions and Additional Information <br /> APPROPRIATE PROTECTIVE CLOTHING <br /> i "EMERGENCY CONTACT: (209) 667-6692" <br /> i SEE E.R.G. PAGE 31 <br /> f <br /> 16. GENERATOR'S,and CERTIFICATION:an I hereby declare that the contents of Bar transport b are lolly and accurately described above by proper shipping name and are classified, <br /> � packed,marked,and labeled,and are to all respects in proper condition/or transport by highway according to applicable federal,slam and international lows. <br /> Q <br /> V <br /> 11 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 Bre degree I have determined to be <br /> economically practicable and that 1 have selected the practicable method of treatment,storage,or disposed currently available to me which minimizes the present and future <br /> 1 threat t9 human health and the environment;OR, B 1 am a small quantity generator,1 have made a good faith effort to minimize my wart generation and select Bre best �I <br /> N <br /> o: wage mum ,menti method that is available to me and that I can afford. <br /> O Printed/Typed Name art n I horpe agent aft Sigmture .-_ . Mantic Dar Year <br /> for Teresi Trucking ��cc . Lt '� t J 0 2 1 914 <br /> Z t 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w A Printed/Typed Name signature L �' Month Day Year :{ <br /> ceNS T <br /> Joe Puett 0 14 12 1 7 1 914 <br /> w <br /> 0 18. Transporter 2 Acknowledgement of Receipt 0l Materials <br /> w j Printed/Typed Name Sigm toe MaaBs Day Yen <br /> W <br /> Q R <br /> w 19. Discrepant/Indication Space <br /> N <br /> Q Is 1 <br /> U A <br /> Z_ C <br /> I IL <br /> I 20. Facil' Owner or at <br /> Gor Certification of receiptof hazardous materials covered this manifest exceptm noted in Item 19. <br /> T Printed/Typed Nome signature Month Day Year 'I <br /> j r <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (7/92) <br /> EPA 8700-22 Yc11,,w: GENFF.ATOR RETAINS g <br />