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- <br /> Y <br /> Please ppnnntortype <br /> (Form designed far use oa elite(12 pitch)tYP �j <br />' NON-HAZARDOUS 1 Generators US EPA ID No Manifest Doc No 2 Pagel <br /> AdLT_ WASTE MANIFEST N/a 00001 1ef 1 <br /> 3 Generator's Name and Mailing Address <br /> x cheveron <br /> hwy 12 lode , ca ti x5 <br /> 4 Generator's Phone( r <br /> 209 ) 467-1006 <br /> r 5 Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone <br />' t thrifty rooter n a 530-673-8201 <br /> 7 Transporter 2 Company Name a US EPA ID Number B Transporters Phone <br />' y 9 Designated Facility Name and Site Address 10 US EPA ID Number C Faahty s Phone r <br /> lnviro tec ; <br /> i 2480 athens ave `Y <br /> Lincoln, ca 95648 n a 434-0211 <br /> 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit <br /> No Type Quantity WUVoI <br /> a non haz waste Liquid nos <br /> waste water <br /> G b <br /> ;z E <br /> N <br /> E <br /> r' R <br /> A c <br /> T <br /> O <br /> R d <br /> m <br />' Moor D Additional Descnptwns for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> purge water from tank <br /> 1 " <br /> 15 Special Handling Instructions and Additional Information <br /> emg // abco y <br />' troy w. 916-826-3803 <br /> A <br />' 16 GENERATORS CERTIFICATION I certry the matanais described above on Ihrs manrfest are not subiect to federal regulations for repoHing proper disposal of Hazardous Waste <br /> Pnntedfryped Name Signature Month Day Year <br /> TR 17 Transponer 1 Acknowledgement of Receipt of Matenals c <br />' A PnntedfTyped Name Signature Mgtith Q Year <br /> N BILL ARTAMENK0 02 <br /> S <br /> P <br /> O 18 Transporter 2 Acknowledgement of Receipt of Matenals <br />' T PnntedfTyped NameSignature Month Day Year <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br />' F <br /> A <br /> C <br /> 20 <br /> T Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as not tem 19 <br />' <br /> Y Printed/Typed Name Signature �/ Moran Day Year <br /> /< <br /> "'L ARTAMENKO <br />' Pnnted by J J KELLER&ASSOCIATES INC <br /> Neenah WI 549570308 12-BLS-05 Rev 12/98 <br /> ORIGINAL- RETURN TO GENERATOR <br />