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Please pram or type <br /> (Form dea{gned for use on el*o(12-pitch)typewriter) <br />' NON-HAZARDOUS 1 Generator's U5 EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST N/a 0001 1 of 1 <br /> 3 Generators Name and Malting Address <br /> Cheveron <br /> hwy 12 lode , ca ^` <br /> I`lz 4 Generator's Phone( 209-y467-1006 tlm ; <br /> "`� 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone {,wt <br /> 1 ° � thrifty rooter n/a 673-1923 <br /> r° 7 Transporter 2 Company Name a US EPA ID Number B Transporter's Phone <br /> 9Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> inviro tec n/a 434-0211 <br /> r� 2480 athens ave <br /> lrncoln, ca 95648 <br /> 13 14w <br /> ( � 11 Waste Shipping Name and Description 12 Containers Total Unit j <br /> No Type Quantity WWoI <br /> a 4000 g a v. <br /> a non haz waste liquid nos 0 <br /> 01 ttIS waste water <br /> o <br /> 1 © i <br /> .4- G b a< <br /> N <br /> E <br /> 01 R �"C] <br /> A c <br /> rv. O'h`1 <br /> ' R x <br /> Zvi Ya� <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Caries for Wastes lasted Above <br /> #; purge water <br /> ' waste water from tank _ - <br /> aE y <br /> 7 <br /> 15 Special Handling Instructions and Additional Information <br /> o-' <br /> F9 emg // abco r gs <br /> Y� troy // 916-826-3803 <br /> � P i <br /> rr <br /> 16 GENERATOR S CERTIFICATION I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposat of Hazardous Waste T <br /> c s� au <br /> 1,4,$ PrintedlTyped Name Signature Month Day Year <br /> f �r <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br />'h �P�intedlTyped Na Sin ur � Monrh Day yo <br /> N IJ rLA C!w J a <br /> 4 <br /> b, O 18 Transporter 2 Acknowledgement of Receipt of Materials ' <br /> '? E Pnntedrryped Name Signature Month Day Year <br /> " R <br /> ESL 19 Discrepancy Indication Space I <br /> F <br /> rp° A *{rx <br /> YaJ1210 <br /> C <br /> Facility Owner ar Operator Certification of receipt of waste materials covered by this manifest except as noted in It <br /> Month Day Year <br /> Pr tQdrr pad Name Sp R ar J �' C� q 5 2 Q o <br /> z l�. artamenko <br />' Printed by J J KELLER&ASSOCIATES INC 12-BLS-05 Rev 12198 <br /> Neenah Wi 54957-0366 ORIGINAL-RETURN TO GENERATOR <br />