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Please pprint ar type � ' <br /> (Form desDgnetl for use on elite(12-pitch)Iy owdtar) <br />' NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST n/a D00� lof 1 <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br /> lode , ca <br />' 4 Generator's Phone( ) <br /> 467-1006 TTM <br /> +" 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br />' z <br /> thrifty rooter67- 18201 <br /> 7 Transporter 2 Company Name a US EPA ID Number B Transporter's Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone j <br /> r <br /> 1T1Vlrt7 teC <br /> 2480 athens ave <br /> lincoln, ca 95648 n 13 14 ` <br />' Iwo 11 Waste Shipping Name and Description 12 Containers Tonal Unit <br /> No Type Quantity Wtfvol <br /> a <br /> non haz waste liquid nos <br /> waste water ad ` ' <br /> 4� <br /> G b <br /> E <br /> N <br /> R <br /> A c <br /> T <br />' R ,r <br /> d <br /> �e <br /> D Additional Descnptions 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 />' emerg abco <br /> troy w. 826-3803 <br />' t <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste <br /> t Pnnted/Typed Name Signature Month Day Year '- <br /> 1 ' <br /> f' - <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br />' INA P ed N e Si a Month Day Year <br /> YP G5 <br /> IN I <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> T Pnnted/Typed Name Signature Month Day Year <br /> 1 E , <br /> R <br /> 19 Discrepancy Indication Space <br />' F <br /> A <br /> C <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br />' Y <br /> Printed/Typed Name lgnatur ` Dy Year <br />' Pnnted by J J KELLER&ASSOCIATES INC 12-13LS-05 Rev 12198 <br /> Neenah WI 54957-0368 ORIGINAL- RETURN TO GENERATOR <br />