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btateofCalifornia--Health and Welfare Agency Tank R;_Ii 1 r S r See Instructions on Back of Page 6 Department of Health Services Form Approved OMB No.2050-0039(Expires 9-30-91) and Front of P 7 Toxic Substances Control Division Please print or type. (Form designed for use on eli�2-pitch typewriter). Sacramento,California UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page 1 Document No. Information in the shaded areas WASTE MANIFEST r of is not required by Federal law. 3. Generator's Name and Mailing Address A. State Man' s o uGn N ft OO�Ii'taLl1S Water SyS�eL1S gO71 L� 2-120 W:-1.c o Y• Rd , S t o C t o n; CA 952 0 R. B. State Generator's ID 4. Generator's Phone( 2 0 9 O-11 3210 Lo 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tranaporter's ID n cu O.C.S . L D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID 004232 ao F. Transporter's Phone 209 485 5495 J f++ 9. Designated Facility Name and Site Address 10. US EPA ID Number Ge. tgte Facility's� D?3 -) l a Gibson Oil Refining Co C A ID 980 1g 3300 i r u X t u n Ave #120 H. Facility's Phone Q Z O 12. Containers 1 ota 14. V LL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) I' Quantity Unit Waste No. a No. Type Wt/Vol State E Ca if reculated :paste on.-Ly N.O., S . ��Q Q22 EPA/Otr E b. 0 ' 'P G iii R �g > :;If `w A Stco A .s Op T O v � EPA/Other v R C. 00 JUN � �� 1 State � h'` �} L{+�I ` L n Cr E-NVIft0NMENTAL t E LTR EPA/Other LU d. Z State w U w EPA/Other rn J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above Z O a. b. Cn Waste water 95% LU Waste fuel mus or m.-inus 5% R-Ol J l C. d. a Z O Q15. Special Handling Instructions and Additional Information Z = Refer to invoice u .� C6 J i Q U 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. 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 o to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to 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 good faith effort to minimize my waste U generation and select the best waste management method that is available to rre and that I can aff0rd- Z " hinted/Typed Narne Signaturei a Month Day Year W14 -M W �.: .7 T 17. Transporter 1 Acknowledgement of Receipt of Materials Z R < A Printed/Typed Name N Signal Month Day Year LL A o P ¢ Wa( Pr r W O 18. Transporter 2 cknowledgement of Receipt of Materials U E Prp�d/Typed Name Sign ure Month Day Year Z fi ll t_ �.A �N vQt:s o 19. Discrepancy Indication Space F A C I L 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. T y Pri /Typed Name Signet Month Day Year DHA 8022 700 rr EPA 8700-222 A /a8) Do Not Write Below This Line (Rev.9-88)Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS To: P.O. Box 3000, Sacramento, CA 95812