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Please print a type <br /> {Form designed torose on eine(12 pilcfi)typewAter) <br /> NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Pagel <br /> WASTE MANIFEST n1a I Q001. V I <br /> 3 Generator's Name and Mailing Address <br /> Cheveron <br /> lode., ca S <br /> 115" 4 Generator's Phone( 2 0 9) 467-1006 <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone t <br /> I ` <br /> thrifty rooter673-8201 <br /> 7 Transporter 2 Company Name a US EPA ID Number B Transporter's Phone <br /> {d p <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facilitys Phone <br /> xnviro tee <br /> 2480 athens ave . ; <br /> lincolu ca 95648 434-0295 <br />' 12 Containers <br /> 13 14 <br /> 11 Waste Shipping Name and Description Total Und <br /> ` Na Type Quantity WtlVol r;y <br /> a non haz liquid waste nos 001. tt <br /> i 4r <br /> ;Y waste water i <br /> G b <br /> E <br /> ` N <br /> I b` R <br /> A c <br /> T <br /> O <br /> R 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 /> emerg abco <br />' troy w. 826-3803 <br /> 1 r <br /> 16 GENERATOR'S CERTIFICATION I certify the matenais described above on this manifest are not subject to federal regulations for reporting proper disposal or Hazardous Waste <br /> Printed/Typed Name Signature Month Day Year _ <br /> r <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br />' N ted/Type N r S n ur Morar DayYear } <br /> S D Lo 61 <br /> P <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br />' r T Pnntedrryped Name Signa#ore Month Day Year <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 2jPnnLt.dVfTyped <br /> Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br />' Y Name <br /> Month Day Year <br />' Pnnted by J S KELLER$ASSOCIATES INC 12-BLS-05 Rev 12198 <br /> Neenah WI 54957-0368 <br /> ORIGINAL- RETURN TO GENERATOR <br />