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Please prim or type <br /> {Form designed for use on elite(12Katch)typewriter <br />' ",'IL-j-NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST n/a 0001 1 of 1 <br /> 3 Generators Name and Marling Address <br /> cheveron <br /> lode , ca <br />' u 4 Generator's Phone( 209) 467-1006 tlm <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> thrifty rooter n/a 673-8201 <br /> I � s <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> d <br /> J' <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> inviro tec k <br /> 2480 athens ave <br /> „ lincoln, ca 95648 n/a 434-0211 r� <br /> 3 i4 <br /> 11 Waste Shipping Name and Description 12 Containers Tonal Unit <br /> No Type Quantity WVVol <br /> a non haz waste liquid <br /> waste water 001 tt cT a ,;, <br /> S � <br /> G b <br /> E <br /> N <br /> E y <br /> R <br /> _ A c <br /> T <br /> O <br /> R d I <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above ` <br /> purge water from tank <br /> ,rt <br /> , <br /> 15 Special Handling instructions and Additional Information <br />' emrg contact; abco ; troy w. 916-826-3803 <br /> 1 y <br /> 16 GENERATOR'S CERTIFICATION I eertlty the matenals descnbed above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Wane <br /> Printed/Typed Name Signature Month Day Year <br /> 1; <br /> T 17 ans orter 1 Acknowledge nt of Receipt of Materials <br /> R - <br />' P edlTyped Name S tura y <br /> 5 �1 n I it- kLk/ dr <br /> P <br /> R 18 Transporter 2 Acknowledgement o eceipt of Materials <br /> T Printed/Typed Name Signature Month pay Year <br /> a R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1'aFacititywner or operatorCertification of receipt of waste matenals covered by this manifest except as noted In Item 19 <br /> Yyped Name Signature - —, Monfh Oay Year <br /> ARTAMENKO ' ut,� �- <br /> ���° 9 127 2 <br />' Printed by J J KELLER&ASSOCIATES $NC 12-BLS-05 Rev 12198 <br /> Neenah WI 50.9570368 ORIGINAL- RETURN TO GENERATOR <br />