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fA <br /> �e5$e pffrit of(yp8 <br /> (Form designed for use on elite(12-pitch)typewfilw) <br />' NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFESTof <br /> n <br /> 3 Generators Name and Mailing Address <br /> cheveron ' <br /> hwy 12// lode , ca = <br /> 4 Generators Phone{ 209 467-1006 tzm <br /> S Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone m <br /> 4-1409.11 <br />' 7 Transporter 2 Company Name a US EPA ID Number B Transporters Phone <br /> i <br /> F t� <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone ~ <br /> inviro tec <br /> 2480 athens aveJ :Lncoln, ca 95648 Z;q <br /> 434--0211 - <br />' -` 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit , N� <br /> No Type Quantity Wt/Vol , <br /> a non haz waste liquid nos 001 tt 1700 ga ,'� <br /> 1 � S <br /> Y, G b <br /> E <br /> N <br />' E <br /> R <br /> A c }: <br /> T <br />' ❑ <br /> R <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> purge water from tank <br /> 15 Special Handling Instructions and Additional Information <br />' emij // xx abco <br /> troy w. 916 .826-3803 <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above an this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste <br />' Printed/Typed NameSignature Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br />' R <br /> A Pnntedfryped Name Signature Mo pay Year <br /> Pbill artamenkom <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br />' E Printed/Typed Name Signature Month Day Year <br /> R <br /> 19 Discrepancy Indication Space <br />' F <br /> A <br /> C <br /> Facility Owneor Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br />' I!Printed/TypedIrNao-p.""It')' <br /> Signature <br /> Month 17a <br />' Printed by J J KELLER&ASSOCIATES INC 12-BLS-05 Rev 1 c1�$ <br /> Neenah Wi 54957-0368 ORIGINAL- RETURN TO GENERATOR <br />