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State of CaWomia—Health and Welfare Agency Department of Hearth Services <br /> See Instructions on back V' 'Cge 6. Toxic Substances Control Program <br /> Please printf or type. Forth designed for use on a6fe(72-piwwrtter). Sacramento,California <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest Document 2.Page I Information in the shaded areas <br /> WASTE MANIFEST C 1 1 1 L I 0 I 0 I 0 I 0 I 0 9 1 8 1 5 I ? O 1 '� 1 0 1 0 1 of a not required by Fedoa kw. <br /> •Ilgrators Name and Marling Address A,State Manifest Document Number <br /> ? 0. Sox 5811, San Mateo, CA 94102 3SrateGenerat«: <br /> a GeneratorsPttone(415 ) 571-2434/571-2428 <br /> 5.Transporter I Company Name 6.US EPA 0 Number C.State.Ttnnsporters EQ 20055 <br /> H & H Ship Service Company 1 A 17 I7 1 o D. Transporterspttorte .543-4835 <br /> 7.Transporter 2 Company Name 8.US EPA 10 Number E.State Transporters 10 <br /> oo I I I I I I I I I 1 ?P..TraruporteFs Phone <br /> n 9. nated m <br /> sty Nae and Site Address 10.US EPA ID Number G Stat@ facAlfy"s�i <br /> ff' H ip Servi.ce Company Ci:AE D 0-0: 47 7 t 1>E 1 t 6 E 3 <br /> 220 China, Basin Street H focii phone <br /> San Francisco, CA 94107 , , , ,a , , , 11 , t �.d <br /> 12.Containers 13,Total 14 UM <br /> 11.US DOT Description(inckiding Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I..Woste Ntznlw <br /> J a. safe <br /> J <br /> v G RESIDUE GASOLINE TANK ,.A� hw_ <br /> Ln g E NON-RCRA HAZARDOUS WASTE SOLID 0 10 1 TIP 1 I O 10 0 0 P <br /> c N b stat@ <br /> Mp E <br /> rl-J R <br /> Q A <br /> OU T c <br /> z ; <br /> LO R EPA/Omer <br /> N d Bharat <br /> O <br /> 00 <br /> Q <br /> (V <br /> V I I I <br /> 0 <br /> 0 J:Addihonol Descmotiors W.Materk*Ested Above G HarxHrng Codes.for Wastes tared Above <br /> I 1 I <br /> crab on �a k a� aA as ng: a b <br /> Owl <br /> arcs ��.� T`an�t �uext�c� w�thl ice nr <br /> z <br /> � ro- <br /> w <br /> U 15.Special Handling Instructions and Adatioral Information <br /> JOB 49660 JOB SITE: ARCO AM/PM, #2076 <br /> 0 24 Hr. Emergency Contact: H & H 4(415) 543-4835 800 E. Rettleman Lane <br /> w APPROPRIATE PROTECTIVE CLOTHING AND RESPIRATOR. Lodi, California <br /> c <br /> J <br /> Q 16. GENERATORS CBMIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> Z pocked,marked,and labeled.and are vt all respects in proper condition for transport by highway according to applicable irtfematbrtal and national government regulations. <br /> O <br /> QN 1 am a large quantity generator.I certify that I have a program in ploce to reduce the volume and toxicity of waste generated to the degree t have determined to be <br /> Z economically practicable and that I have selected the practicable method of treatment,storage.or disposal currently available to me which minimees the present and future <br /> uantify generator.I have mode a good faith effort to minimize my wage generation and se ecu the best waste <br /> LU threat to human health and the erwironmenh:OR.if I am a small q <br /> = management method that is available to me and that i can afford <br /> PnntediTypea Name Signature MonLb <br /> m Y Year <br /> a <br /> !!>�2c' 111 �2 10 ( 9 I 1 <br /> Cn 17.Tr porter 1 Acknowledgement of Re t of Materials <br /> C i <br /> Q Q Pnnted/Typed Name S Month %cy Year <br /> > A <br /> 5 NOR VAN L. BERG �d\r 1 1 11 12 10 19 1 1 <br /> Q11 Transporter 2 Acknowledgement of Peceiot of Materials <br /> � Q Printed/Typed Name Signature Month Dav Yea <br /> L T <br /> OE <br /> LU <br /> QF 19.Discrepancy Indication Space <br /> U A <br /> z C <br /> I <br /> 20.Fac,lity Owner or Operator Certfication of race pi of i�araoLa materials covered by this mcnifest em 19. <br /> LTPrinted/Typed Name Signature Month Dayj��` 24Year <br /> NOT WRITE 3E THIS UNE. <br /> DHS 8022A(12/90) <br /> EPA 3700-22 <br />