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State of Calilornin -Health and Welfare Agencyn., <br /> Deparbnenl of Healt <br /> Form Approved OMD No.2050-0039( 'es 9-30-88) Toxic Subna Cont, <br /> ramerito <br /> Please rint or type. (Form desi ned on afe 12- itch f ewriter. <br /> UNIFORM HA 1. Generator's US EPA ID No. Document attest 2 Page 1 Information In ah4(led <br /> WASTE MANIFEST <br /> CAI � � 01 7 °I <br /> is require by FeQPrel <br /> 3. Generator's Name and Mailing Agtlresa U �' IO uA / < L n vie A, State Manifest Document Number <br /> Ar <br /> r fT F' l •!4'�G <br /> Ll a el S ( S r 1f /(� �k q C,�, B. State Generator's to <br /> 4 Goner alum Phone( ) V <br /> . Transporter I Company Name 8:• US EPA ID Number C. State Transporter's ID <br /> 72 _ r'(-+ 7 2 03D. Tranaporter'n Phone 800 4-4u <br /> 1 7. Transponer 2 Company Name 8. US EPA ID Number . Stele Transporter <br /> ID <br /> a' F. Transporter's Phone ' <br /> 9. Designated Facility Name and Site Address 10.' US'EPA ID Number G. State Facility's ID <br /> Refineries SErviCd ( It U U 8 l b 6 P E <br /> 13331 l4.Hwy. 33 1 Facility's Phone <br /> z <br /> Oa�cerson Ca 55363 i 0 t 3 1 V '7 s" b 800. 874 4444 ' <br /> 12. Containers '13. Total 74. I. <br /> 11. US DOT Descrill(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste <br /> 4. No. Type - Wt/vo <br /> a 'w. State <br /> z ' G r <br /> E WA LEO1L HCiS GUMOUS'P'L^L Li(yU1D ,'+. JP. 1 '70 2 lr EPA/)) ar <br /> N <br /> E 0. "1 State'': <br /> R <br /> 1, ,EPA/Other <br /> T <br /> O <br /> R c ti 'State ` <br /> L t , <br /> 7 <br /> Z i1 d Stalep` <br /> r <br /> EPA/Otho* <br /> J-'4d -nal Descriptibna for Materials Listed Above 14 HBDdlin'.Codes tor;Wastes Listed Above <br /> Z p a a to <br /> `?_ ry - <br /> 'uli -c <br /> Z <br /> J <br /> •$pedal Hantllin8 Instrudi s antl Atlditional IPiornation <br /> Z <br /> A <br /> GENERATOR'S CERTIFICATION: ti hereby declare that the contents of this consignment ale fully and accurately described above by proper ship <br /> Jname and are classified, packed, marked, and labeled, and are in all respects in proper?condition for transport by highway according to app�r <br /> c internatid}ttal and national government regulations. t t <br /> If I am a urge quantity generator, I certify that I have a program in place to reduce the volume and toxidity of waste generated to the degrde I In <br /> determined to beeconomically practicable and that I have selected the practicable method of treatment! storage, or dispesal currently ava(Iab <br /> _ me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, i have•made a g <br /> �. <br /> faith <br /> /effort to <br /> minimizes my W/a�sta generationandselect the pgswends management method that is available to me and that I can afford. . <br /> AC/�/V ,Sign u� � f 1 � Month DeY( <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w R <br /> ZZ A Printed/Typed Name .Signature Month Day <br /> w NS Al Greyson <br /> PO 1S. Transporter 2 Acknowledgement of Receipt of Material. <br /> R Printed/Typed Name 'Signature Month Day <br /> 6 T <br /> V E <br /> Z <br /> n9. Disgrdpancy Indication Space - <br /> F l ..\ <br /> A <br /> C le „ <br /> I <br /> L <br /> 1 220. Facility Owner or Operator Codification of receipt of hazarda6.materials covered by this manifest except as noted in Item 19. <br /> TY R-rinted/Typed Name ± . Signature Marth Day <br /> DHS 8022 s(1/87) YUP OW: . _'AERATO:i '.:7Altyf INSTRUCtiIONS ON THE BAC <br /> EPA 8700---22 ,f1 ,/ <br /> (Rev.9.867 Previous editions are Obsolete. <br /> i <br />