Laserfiche WebLink
Vasbtiltemhs.afitorni satin and Weitare Agency bee instructions on Back of Vg b Department of neenn aerviees <br />' vedap No 205tl-0039(Expires 930-9 1) and Front of Page 7 Toxic Substances Control Oivfaion <br /> Please print Oi type Form designed for use on skits(f277itch typewriter) and Sacramento,Caldomia <br /> UNIFORM HAZARDOUS 1Generator'.US EPA tD No Document No Manifest 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST ' + , S' of Is not required by Federal law <br /> 3 Generator a Name and Mailing Addresss M es x <br /> 'A. State trt4tfHest Document*lumber' <br /> Exxon # - _ G? �'� <br /> U.S.A. Station = <br /> P.O box 4415 Houston TX. 77310.-4415 13�slafe Gefierl0.toi'a <br /> 4 Generator a Phone( ) s " <br /> 6 Transporter 1 Company Name 6 US EPA ID Number �StatsTrahappter'aim " sn 'syr <br /> N <br /> f` D'W Triinsportarb <br /> Cv 14 In In In IQ It, 16 <br /> W 7 Transporter 2 Company Name e� US EPA ID Number �E3State lranapnrtsra IDS E«, i"-s� _ r a <br /> .,,.e'�ak"�ez't`. n'�',..i K"6cr'� <br /> d) s <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Numberp <br /> State FaGlfty'a M r A r� <br /> Q <br /> Gibson Oil / Pilot Petroleum �` '4 P �y <br /> v 475 Sea Port Blvd. H FaciHtye� "'s �s FQ R <br /> Qrow <br /> Z O F rtea <br />�0 12 Containers 13 Total 14 1 <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) Quantity Unit waste No <br /> No Type Wt/vol <br /> a RO Hazardous Wabte Liquid N.O.S. state222z <br /> EEPA10ther <br /> N T a -f 1�1 <br /> E b <br /> N R Stats <br /> o A <br /> T ' <br /> IV o <br /> a R c <br /> state <br /> Go <br /> EPA/Other <br /> 1r d <br /> State <br /> Z <br /> W <br /> U EPA101her <br /> w <br /> W J 1lddrtronal Deecnptwn for Matenals,rListed Above z � a ,_' ya, r K 'Handibtg Codes for Wastes Listed Above <br /> Z az �� a+�,.a�ff.�'.`'' .. z ,pi's_,- y -<.-.x mow$ adz s-""''a.. 4 y, i <br /> s ,.�E knw f6�y p�a�. .E �i �r4..,"z �,.�@`y ?x$. a� L u fr wr�� �A�} yes rye i »Y r <br /> g.. ✓«a 4 e`er ,fid 4 �w <br /> 4k .*'_ xn � ee roa:� ,�w'�:-e ae_� �� F2a�.�� ">"smvrx i .c a .� a4 <br /> alg�" �� x � ,�-x,� '"pr �.�..��' � >FCes��� a 't�; �� a ad > <br /> Ili@sal s a � �' " <br /> 0 "' E t n h X�-n y 9 �,w 45- <br /> 16 <br /> ,�.� <br /> 16 Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> Cloves ERG 31, 24hr. Contact Name . � � c� � t ir«�u, Profile 10626 <br /> Site: iii rfi 1.1ntr(4 l4 t~r ph. #t 1800-992-3647 <br /> J rk" rl <br /> J <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 /> i 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 /> 131- national government regulations <br /> cn <br /> If I am a large quantity generator I cedity that I have a program rn place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O 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 />>- <br /> U generation and select the best waste management method that is available to me and that 1 can afford <br /> Z <br /> WPrinted/Typed Name Signet r Month Day Year <br /> W <br /> GQ IF bFtl4PZv f <br /> WT 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> Q A Printed/Typed Name Signatu(e Month Day Year <br /> S <br /> r <br /> O p <br /> L O 18 ra portercknowledgeme t t e eipt of Materials <br /> Printed <br /> J T /Typed Name Signature =Mo-WhDay <br /> E r <br /> Z <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> MLAdbkl 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Panted/Typed Name Signature Month Day Year <br /> HS 6022 A Do Not Wrrte Below This Line <br /> PA 870D-22 <br /> 3ev 6 89)Previous editions are obsolete ,��ti3 r�F <br /> 3 gserrt i'C u^1-- S 17`C YELLOW GENERATOR RETAINS I <br /> �..YyC K-ra�r /' J4$U�l'r11w->io✓ r'-��jr �✓e�.-. Ue<! ron+�!✓r[/J��Ii"i ! <br />