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State of California--Health and Welfare Agency See Instructions on Back of Page 6 Department of Health Services <br /> Form Approved OMB No 2050--0039(Expires 9 30 91) Toxic Substances Control Division <br /> Please pant or type Form designed for use on stile(12 pitch typewriter) <br /> and Front of Page 7 Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator a US EPA 10 No Manifest 2 Page 1 Information in the shaded areas <br /> r WASTE MANIFEST P'i f{ e 11 11 1_ Document o 1 of is not required by Federal law <br /> 11 13 Generator s Name and Mailing Address A (State Manifest Document Number t¢ <br /> Exxon. U.S.A. Station # 7- ;,;3:t- 90648174 <br /> P.C. Box 4415 Houston, Tx. 77310-4415 B State Generator's ID <br /> 4 Generator s Phone( 51CD 246-8785H Y `9 3 6 0 1 9 8'7 �$w <br /> x <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C Stale Transporter's ID- Nt <br /> Erickson, Inc. ( A Dt? G 4 4 5 6 3 9 2 p_ TradsporterePhone R <br /> 7 Transporter 2 Company Name a US EPA ID Number E State Transporter's ID <br /> F Transporters Phone x'" <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G ,State Facikttr's W <br /> rf6son oil f pilot Petroleums, " r u <br /> 475 Sega Port Blvd. tf,Facility aPhone � r <br /> Redwood City, Ca. 94604 ICIAID10j413121610 71012 (510) 366-5511. x <br /> 12 Cantemers 13 Total 14 I l <br /> 1 i US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No c <br /> No Type Wil Vol <br /> a RQ Hazardous Waste Liquid N.A.S. state <br /> 2 ZZ <br /> G EPA/Other <br /> N (}R -E NA 9189 D018C Oil TIT C, i213` F <br /> E b State <br /> R M <br /> A <br /> T EPA/Other >i <br /> R C State <br /> EPA10ther A <br /> id State <br /> } EPA!Other <br /> J Additional Oescriptlons for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> War er 99% e r 8 b <br /> C'a;i <br /> c d <br /> Diesel- t)-5%- <br /> 15 Special Handling Instructions and Additional Information <br /> Cloves ERG 31 2411r. Contact r4ame .{ - }�- Protile 1(3626 <br /> site., << . 'j"•fi�"! t! -� Ph. # 1-800-992--3647 <br /> 18 <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 /> national government regulations <br /> If I am a large quantity generator 1 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 be economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which mmimizea the <br /> present and future threat to human heatth and the environment OR if 1 am a small quantity generator I have made a good faith effort to minimize my waste <br /> generation and select the beat waste manage-vert method that rs available to me and that I can afford <br /> Printed/Typed Name Signet r Month Day Year <br /> 6REG bCMA&-rU 1. V) +t; 1a Y 12- <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed NameSignature Month Day Year <br /> PO 18 Transporter 2 Acknowledgement of Receipt of Materials t <br /> R Pnnted/Typed Name Signature Month Day Year <br /> T <br /> E <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> y Printed/Typed Name Signature Month Day Year <br /> s 8022 A Do Not Write Below This Line <br /> A 57001-22 <br /> iv 8-89)Previous editions are obsolete <br /> YELLOW GENERATOR RETAINS <br />