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' Stete of Cafifornia--Health and Welfare Agency Department of Health Services <br /> Pbrm Approved OMB No.2050039(Expires 9.3r Toxic Substances Control Division <br /> s Please print or type. (Form designed for use on a 2•pifch typewriter). Sacramento,California <br /> f <br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest 2. Page 1 tion in the shaded areas <br /> WASTE MANIFEST ' 1(11C,101 <br /> t I F Document No. <br /> I' if C, !n j - 1 C of Lr-F.I.not required by Federal law. <br /> 3. Generator's Name and Mailing Address I \�- li ' ' ` , t ; A. State Manifest Document Number <br /> CHEVRON U.S.A. INC. �,� t.� (t -1:::6 l�ri �.'i � 8 l <br /> 47 <br /> P.O. Box 5004 B. State Generator's ID <br /> San Ramon, CA 94583 <br /> 4. Generator's Pho ( ) L ` �Zl �'f�i <br /> r L R 4 -4 n r) L i� TI a n -7 q <br /> 5. Transp r t Company Name 6. US EPA ID Number C. State Transporter's ID G> <br /> N <br /> A T T T('K 13c �' i O D. Transporter's Phone , S Y - ,?C f <br /> m <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> O 1 F. Transporter's Phone <br /> • o <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> . r-a GIBSON OIL AND REFIRING COMPANY _ C 14 In 10F, In Is813 1I 1717 11_ <br /> 3121 STANDARD STREET H. Facility's Phone <br /> T-4Z R TF Ti �' r1 G n i ? n 1 -n I <br /> m¢ 12. Containers 13. Total 14. I. <br /> �O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> MZ a. WASTE PETROLEUM HYDROCARBON state 223 <br /> E CONT&MINATED WATER t EPA/Other <br /> 3 N Q 'P TT .1 T VT y — <br /> E b. State <br /> N R <br /> Goo A EPA/Other <br /> T <br /> v 0 <br /> NR C. State <br /> y <br /> 0 <br /> EPA/Other <br /> W d State <br /> Z <br /> Z <br /> LU EPA/Other <br /> U <br /> ' w <br /> rn J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> a. b. <br /> MONITORING WELL DEVELOP2 PTT/PURGE WATER LESS <br /> THAN 5i; PETROLEUM HYDROCARBONS, CREATOR THAN' 95% WATER C. <br /> i a SEE ATTACHED ANALYSIS. <br /> Z <br /> F- 15. Special Handling Instructions and Additional In}Dttlie - <br /> Z JAN 4 11 7 <br /> -W GIBSON OIL WA-STE STFr1 ,1 9037-6.- <br /> ENVIRQNMENTAL 1-41'/1°. 1 ' <br /> ! Q 16. <br /> U <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 are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> a national government regulations. <br /> F ¢ <br /> It 1 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 /> U 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 smell quantity generator,1 have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that 1 can afford. <br /> W Printed/Typed Name Signature Month Day Year <br /> 0 ' <br /> r.� i - j j1 <br /> f w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z RA Prin7yped Name Si9 nature �Z� Mont Day Year <br /> s <br /> f a N �(� L <br /> 't os <br /> P <br /> W O 181 Transporter 2 Acknowledgement of Receipt of Materials <br /> 3 U <br /> Q R Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered b his manifest except as noted in Item 19. <br /> T <br /> ' y Prinffi yped me Signature' / Month Day Year <br /> t <br /> DHS 8022 A(1/88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />