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' Please pttnt or type <br /> (Farm 141nod for use on elate(12-pitch)typewrillm) <br /> `' F NON-HAZARDOUS 1 Generators US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST n/a 001 1 of 1 <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br />' ^;, hwy 12 lode , ca <br /> 4 Generators Phone( 209) 467-1006 tim 3 <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone <br /> thrifty rooter nZa <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> v <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Pacildy's Phone <br />' inviro tec <br /> 2480 athen ave . <br /> llncoln, ca 95648 { <br />' s 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit ` <br /> No Type Quantity WUVoI <br /> 9 <br /> } <br /> S a 4400 <br /> non: haz waste liquid 001 tt <br />' r= waste waterd <br /> G b <br /> E <br /> 1 iT N <br /> r A c <br /> b T <br /> R <br /> d <br />' D Additional Descriptions for Materials Lasted Above E= Handling Codes for Wastes listed Above <br />' waste water from poly holding tank <br /> 15 Special Handling Instructions and Additional Information <br />' A emg # abco <br /> troy w. 916-826-3803 <br /> 1 ' <br /> 16 GENERATOR 5 CERTIFICATION I certify the materials descnbed above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste <br /> Pnnted/Typed Name Signature Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> YfS ed/Typed Na ` Si a re Month Day Year <br /> P <br /> u) ; <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> T Pnnted/Typed NameSignature Month Pay Year <br />' E <br /> R <br /> 19 Discrepancy Indication Space <br />' F <br /> A <br /> C <br /> I <br /> 20Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> Y <br /> wed Name natur Day Year <br />' Printed by J J KELLER g ASSOCIATES INC 12-BLS-05 Rev i'cr 7g <br /> Neenah WI 54957-0368 ORIGINAL- RETURN TO GENERATOR <br />