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Please pnM or typa <br /> {form designed forus0 on ekfte(12 pdch)typew der) <br />' NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST of <br /> n a <br /> 3 Generator S Name and Mailing Address Y <br /> cheveron hwy 12 <br />' lode , ca <br /> 4 Generator's Phone( ) _ <br /> 1006 -Li in <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone <br />' thrifty rooter n/a 673-1023 ; <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> f' <br /> a <br />' y 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone <br /> znviro tec <br /> 2480 athens ave n/a 434 -0211 <br /> lincoln, ca 95648 <br /> 11 Waste Shipping Name and Descnpticn 12 Containers 13 <br /> 3tai Unit <br /> No Type Quantity Wt/Vol , <br /> a non haz waste liquid nos <br /> purge water frcm tank 001 tt a2,., <br /> G b a <br /> E <br /> N <br /> E <br /> R <br /> A c <br /> T <br /> I R + <br /> d <br />' ❑ Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> purge waste water from tank <br /> 15 Special Handling Instructions and Additional Information <br />' emg #abco ' <br /> troy ir. 916-826-3803 <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above on this manifest are not subject to federal regviattons for reporting proper disposal of Hazardous Waste <br />' Printed/Typed Name Signature Month Day Year <br /> T ansporter 1 Acknowled m t of Receipt of Materials <br />' Pnn d/Type(tName Sl nater 1 Day Year <br /> P 17 O 8 Transporter 2 Acknowledgement ofeceipt of Materials <br /> R <br />' E Printed/Typed Name Signature Month Day Year <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20 Facility Owner or Operator Certification of receipt of waste matenals covered by this manifest except as noted in Item 19 <br /> Y <br /> Print ed Name Sign ay Year <br /> L <br />' Printed by J J KELLER$ASSOCIATES INC 12-BLS-05 Rev 12/9$ <br /> Neenah W1 54957-0368 ORIGINAL- RETURN TO GENERATOR <br />