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Slate of California—EnHronme i Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9.30.94) See Instructions on back of page b. <br /> Please Prix or type. Form designed for.on.lfte(I ypit oter. Department of Toxic Substances Control <br /> Sacramento,Coliform. <br /> UNIFORM HAZARDOUS Generators US EPA ID No. Monte"Docu nt No. 2. Page 1 Information in theshaded areas <br /> WASTE MANIFEST 0 A C 0 0 0 7 2 2 1 7 6 8 11 10 8 9 1 is not required by <br /> o Federal law, <br /> Nam j <br /> 3. G nenctoes Naand Mailing Address A.:,State Morsife-- '. x- <br /> N GOLFLAND ARCADE g 2881089 <br /> ^ 7850 N. West Lane, Stockton, CA 952TO Bsae.crI <br /> 4. G. --h-,Phone (209) 477-2424 i• <br /> d0 5. Tmaeparter 1 Crxnpory Name 6. U$EPA ID Number C.State Transporter',ID ` <br /> NOR CAL OIL CAD 19 18 12 14 1117 j2 5 5 1°':T`°nsparte'sPn°"e (2 9) 667;-6692 <br /> 7. Truaporivr 2 Ca M."Nome B. US EPA ID Number <br /> E, Store Tramportn's ID <br /> U <br /> Tran,porteds:Phone <br /> Z 9. Dasiynded Facility Name and Site Address 10. US EPA ID Number !G .State FacilBy4.ID <br /> coo REFINERIES SERVICE ICIAID10f813111616171213 <br /> O13331 N. Hwy 33 H Facility's Phone <br /> r-1 U Pat% rison, CA 95362 CAD 0 8 3 1 6 6 7 2 81 (80G),874-41 44 <br /> a0Z It. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Comainers 13. Tool 14. U".t <br /> COR No. T e Quantity wt/Vol 1'Waste-N 6 r <br /> N� NON-RCRA HAZARDOUS WASTE LIQUID Sloe <br /> Q? E EPAlOther <br /> (WATER & X01 OIL) O O l T T p 223 <br /> OD O G <br /> N b. sore... <br /> A - EPA/Other <br /> T.m U ` Stora <br /> C R EPA/Ctther <br /> Z <br /> z d <br /> U <br /> Z <br /> o. <br /> N <br /> W <br /> J <br /> Z <br /> O 15. Special Handling Inslructiom and Addilio..I Information <br /> APPROPRIATE. PROTECTIVE CLOTHING <br /> W "EMERGENCY CONTACT: (209) 667-6692" <br /> SEE E.R.G. PAGE 31 <br /> 16_GENERATOR'S CERTIFICATION: I hereby declare that the contents of the is are fully and accurately described above by proper shipping name and aro dossified, <br /> Q packed,marked,and labeled,and aro in all respects in proper condition for transport by highway according to applicable federal,sloe and international laws. <br /> U <br /> -.i If 1 am a large quanmy generator, I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of trealmerrp storage,or disposal currently available to me which minimizes the present and future <br /> sit, three to human health and the mr ironmeo;OR, if 1 am a small quantity generator, I hove made a good faith effort to minimize,my waste generation and select the best <br /> waste mane .me.method Mat is available b ma and that I can afford. <br /> Q Printed/Typed Name gent Dt'. Sign re Momh Day Year <br /> U GOLFLAND ARCADE <br /> Z p. 17. Transporter 1 Acknowledgement of jilisfe.F.of Materials <br /> W A Primed/Typed Name Si naNre <br /> N 9 Month Day Year <br /> W 5 1✓ <br /> P <br /> a. 18. Transporter 2 Acknowsp <br /> led emmt of Reeei 1 of Materioh -s <br /> u e- <br /> s4 r Primed/Typed Nemo- <br /> I� `•. Si ro Momh Dap Year <br /> N 19..Discrepancy Indication Space <br /> < IF <br /> U A <br /> 2 <br /> _ I <br /> L <br /> 1 20:.Facility Owner or Operator Certifications of receipt of hazardous materials covered by this manifest extent as need in hem 19. <br /> Typ <br /> Y" Pried Name-. Signature- -. Momlr- Day Year <br /> ) <br /> DO NOT-WRIT : ELO T Ed <br /> DTSC8022A (7/92r - - While: TSDF SENDS THIS.COPY TO DTSC WITHIN 30 DAYS. <br /> EPA:8700-22• - To, P.O. Box 3000, Sacramento, CA' 95812 - <br />