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State of California—Health and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9.30-91) r�o Toxic Substances Control Division <br /> ,Please print or type. (Form designed for use on eli( '.pitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Pae 1 <br /> Doc ment No. g f` Information in the shaded areas <br /> WASTE MANIFEST CI �} {� Q (,} J O �I O 1 �f L ! of is not required by Federal law. <br /> 3. r' a d ailin d reqs / : A. State Manifest Document Number <br /> ��d�dtS' ��.�. �R�. ,�.��� �U . fit �-1� ;'x t n � -�1-� 8 <br /> P.O. Box 5004 9533346 <br /> San Ramon, CA 94583 f j� j B. State Generator's ID <br /> 4. Generator's Phone(425) 842-9500 A A ff iQ 13 16 0 2 17 8 13 <br /> U) 5. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter'a ID <br /> to <br /> ERICKSON TRUCKING, INC, ICIAIDJOI019141616131912 D. Transporter•sPhone (425)235-1393 <br /> N <br /> 'o 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> . ao <br /> F. Transporter's Phone <br /> 0 <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> co GIBSON OIL AND REFINING COMPANY, INC. C 9 $ 10 18 18 13 11 17 17 It <br /> U COMMERCIAL DRIVE H. Facility's Phone <br /> M:5 BAKERSFIELD CA, 93308 ICIAID191810181813111717 (805)327-041 <br /> M¢ 12. Containers 13. Total 14. 1. <br /> O <br /> (Y�0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt Vol <br /> State <br /> C v a- WASTE PETROLEUM HYDROCARBON 22 <br /> FG CONTAMINATED WATER EPlrlOt r <br /> E <br /> N CALIFORNIA REGULATED WASTE ONLY () 0 2 <br /> 3 <br /> E b. State <br /> ii R <br /> mT EPA/Other <br /> N O <br /> v R C. State <br /> 0 <br /> EPA/Other <br /> Lu d. State <br /> I— <br /> Z <br /> W <br /> L) EPA/Other <br /> W <br /> to J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 0. a. j b. <br /> 0. MONITORING WELL DEVELOPMENT/PURGE WATER LESS / <br /> Lu THAN 5% PETROLEUM HYDROCARBONS, CREATOR THAN 95% WATER c. d. <br /> z SEE ATTACHED ANALYSIS. <br /> 0 <br /> ~¢ 15. Special Handling Instructions and Additional Information j� <br /> Z <br /> GIBSON 01L WASTE STREAM 8037-b. ���t <br /> FEB 2 <br /> '1 <br /> LTI <br />' J <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descrilgi�bW by jeer shipping name <br /> and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> CLnational government regulations. <br /> ir 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 /> p to be 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 small quantity generator,i have made a good faith effort to minimize my waste <br /> L) generation and select the best waste management method that is available to me and that I can afford. <br /> 0Printed/Typed Name gna ure Month Day Year <br /> LU �tl RG l 4� <br /> LU 9 <br /> wT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name r. Signature Month Day Year <br /> `' Hh i <br /> 0 P <br /> w O 18. Transporter 2 Acknowledgement of Receipt of Matertais <br /> UT Printed/Typed Name Signature Month Day Year <br /> E <br /> Z_ <br /> 19. Disicetion Spaoe `��\ �^Ct <br /> F <br /> A <br /> C <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> Y Printgdayped Name /� Sig _ Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previoys editions are obsolete. <br /> - ! Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />