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ff,a'a of Ca1ilomle�iealth and Waitare Agency <br /> rtn Appcovatl OME No.2050--0039(Expires 9.30-91) See Instructions on Back of Page 6 Department of Health Services <br /> ase print or type. Form designed for use on elite(12-pit ewriter). and Front of Page 7 Toxic Substances Control Division <br /> UNIFORM HAZARDOUS f. Gen .Ir's US EPA ID No. Sacramento,Calitomia <br /> WASTE MANIFESTMenifeat 2. age' <br /> oc met o. Information In the shaded areae <br /> 3. Generator's Name and Mailing Address of 1 Is not required by Federal few. <br /> SULLIVAN AND MANN LUMBER CO A. State Manifest DoI91 UUMD" 3 <br /> 16177 SOUTH MCKINLEY, LATHROP, CA 95330 B. State Generators to 9 U44119 <br /> 4. Generator's Phone(209) 858-4737 <br /> 5. Transporter 1 Company Name <br /> e. US EPA ID Number C. State ID TreMIPortera l <br /> NOR CAL OIL A D 9 one <br /> 8 2 4 1 7 2 5 D. Tranaportar'a Ph <br /> f. Transporter 2 Company Name <br /> 8. US EPA ID Number E. State Tran <br /> apotter'a ID <br /> 9. Designated Facility Name and Site AddressF. Tranapartar'e Phone <br /> 10. US EPA ID Number G. State Facility's ID <br /> REFINERIES SERVICE <br /> 13331 NORTH HWY. 33 H. Facfllty'a Phone <br /> PATTERSON CA 95363 218 (800) 874-4444 <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and 10 Number) 12. Containers 13. Total 14. I. <br /> Quantity Unit Waste No. <br /> e. No. Type Wt/Vof <br /> G HAZARDOUS WASTE LIQUID N.O.S. stare 134 <br /> N RM—E NA-9189 EPA/other <br /> E b. <br /> R <br /> A State <br /> T <br /> O <br /> R EPA/Other <br /> c. <br /> State <br /> EPA/Other <br /> d. <br /> State <br /> J. Additional Descriptions for Materiels liatetl Above EPA/Other <br /> K. Handling Code,for Wastes I-I red Above <br /> TANK BOTTOM WASTE a. b. <br /> RINSATE <br /> 15. Special Handling Instructions and Atlditional Information <br /> 1 <br /> APPROPRIATE PROT'ECT'IVE <br /> CLOTHING AND RESPIRATOR EMERGENCY CONTACT; 800-332-8710" <br /> i6. <br /> 1 ;1 ' 1 <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 ars classified,packed,marked,and labeled,and are In all respects in proper condition for transport c highway according to applicable international and <br /> national government regulations. <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 ba economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,if I am a am <br /> generation and select the best waste management method that is availebl mo an ihet generator,can fford.have made a good faith effort to minimize my waste <br /> Prince /Tfpetl ma /y/ - <br /> / i /7 Signature Month Day Year <br /> I I ` ilii//( <br /> IT Transporter 1 Acknowledgement of Receipt o Materials 19 �� L <br /> Printed/Typed Name <br /> . Signature <br /> 1 Month Day Year <br /> 19. Transporter 2 Acknowledgement of Receipt of Materials /C} <br /> Printed/Typed Neme <br /> Signature <br /> Month Day Year <br /> 19. Discrepancy Indication Space ti <br /> 20. Facility Owner or Operator Certification of receipt of hazer'ous materials covered by title manliest except ea noted in Item 19. <br /> Printed/Typed Name <br /> Signature Month Ve <br /> 66 2CG� y Year <br /> 2A � <br />)-22 Do Not Write Below Thi the <br /> 9)Previous editions are obsolete. <br /> White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS , <br /> To: P.O. Box 3000, Sacramento, CA 95812 <br />