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State of Califomle-41ea91t and Welfare Agency <br />Foran Approved CMD No. 2050--0039 (Expires 9.30.1 <br />Q1 <br />SCE! <br />In <br />a) <br />W/ <br />(DO <br />n <br />.rlwee <br />print or type. (Form designed for use on ell pooh typewriter). <br />Toxic Substances Control Dlvla , <br />UNIFORM HAZARDOUS Generators U3 EPA ID No. Manifest <br />Sacramento. Commit <br />7r <br />WASTE MANIFEST Document No. <br />2. papa 1 <br />Information In the shaded areas <br />- <br />3. Generator Name and Mailing Address <br />of is not required by Federal law. <br />SAS A J _ <br />a�e7- E w l." � A�c <br />A. State Manifest Document Number <br />Q - <br />V <br />4. Geife8195199 <br />(�7 (i..D <br />rator's Phone (;� Jr) <j <) <br />3c�7' <br />a. State Generators ID <br />0 <br />5. Transporter 1 Company Name 8. <br />n <br />US EPA ID Number <br />C. State Transporter's ID <br />D. Treneporter'e Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number6 <br />67 <br />E. State Treneporter'e I <br />r9 <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G: State Fa<Ility's ID <br />J <br />Erickson, Inc. <br />258 Parr BIVd. <br />< <br />Richmond, Ca. 94801 <br />H. Facility's Phone <br />E <br />T <br />i <br />11. US DOT Description (Including Proper Shipping <br />P PPing Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />. <br />J <br />a <br />No. <br />Type <br />Ouantity <br />Unit <br />Wt/Vol <br />Waste No. <br />G <br />Waste Empty Storage Tank <br />State512 <br />N <br />California Regulated Waste Only <br />O O <br />EPA/O her <br />E <br />b. <br />1 <br />T P <br />0 0 5 5 0 <br />P <br />None <br />R <br />D A <br />o T <br />r <br />State <br />U <br />EPA/Omer, <br />? R <br />a <br />J <br />State <br />0 <br />EPA/Other <br />State <br />i <br />/ <br />EPA/Other <br />? <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />i <br />a. n. <br />Empty Waste oil tank;. <br />dryice <br />. <br />a. <br />i <br />15. Special Handling Instructions and Additional Information <br />i6. <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 <br />national government regulations. <br />according to applicable international and <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 I have determined <br />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal <br />currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste <br />generation and select the best <br />waste management method that is available to me and that I can afford. <br />VT <br />Printed/Typed Name <br />Signa <br />�/C <br />r Month Gey year <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />i <br />R <br />N <br />Printed/Typed `ame <br />Signature <br />S <br />,,(`A/ <br />119 I "\ AT{- <br />Month Day Year <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materiels <br />RPrinted/T <br />T <br />yped Name Signature <br />E <br />Month Day Year <br />cre <br />19. Dispancy Indication Space <br />- <br />F <br />A <br />I <br />L <br />I <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this menileel except as noted in Item <br />it <br />y <br />Printed/Typed Name <br />Signature <br />—Dy <br />Month Year <br />ENVIRONMEN <br />8022 A <br />(1 /e8)Bri <br />1. <br />DHS <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions are obsolete. <br />vo Not vvnte aglow [his Line ' ""^tutgLKVI I <br />Blue: GENERATOR SENDS THIS TO DOHS WITHIN 30 DAYS <br />TO: P.O. Box 400, Socromellfo, CA 95812-M <br />