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Please print or type <br /> (Form designed for use on elite(12-pitch)typownter) <br />' NON-HAZARDOUS 1 Generator's US EPA It)No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST n/a 0001 1 of 1 <br /> 141 3 Generator's Name and Mailing Address <br /> cheveron <br /> lodi. , ca <br />' 4 Generators Phone( 209 -71 6 t im <br /> 209 46 as , <br /> r 5 Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone <br /> thrifty rooter n/a 673-1923 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporters Phone <br /> aN 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone ;mow <br /> ri{ lnvlro tec <br /> r 2480 athens ave <br /> lincoln, ca 95648 n/a 434-0211 <br /> 12 Containers 13 14 -_1 <br /> 11 Waste Shipping Name and Desenption Total Unit I, <br /> No Type Ouantrty Wt(Vol 1i- <br /> anon haz liquid waste 001 tt � � gal <br /> waste water <br /> GCC b <br /> E <br /> R <br /> V A c <br /> T <br /> 1 R <br /> ear_ R r�LL <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above -= <br /> purge water from poly tank <br /> 15 Special Handling Instructions and Additional Information <br /> emg contact abco /troy w. 916-826-3803 r' <br /> r,x , <br /> 01 <br /> 11 <br /> ' SJ <br /> 16 GENERATOR'S CERTIFICATION I certify the metenals described above on fhis manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste <br /> 01VMonth Day Year <br /> 4� Pnnted/Typed Name Signature <br /> i� R � <br /> r � <br /> T 17 T er 1.#cknowledgementA Receipt of Materials <br /> w� <br /> €; R Mo GY Year k", <br /> A Pnnt� d Name n <br /> N _ <br /> r P <br /> i O 18 Transporter 2 Acknowledgement eceipt of Materials <br /> T Printed/Typed Name g t <br /> R Signature Month Day Year fe <br /> �•p E <br /> _ R t <br /> 19 Discrepancy Indication Space fir" <br /> s A <br /> C <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> Y Printed/Typed Name Si Month Day Year <br /> BILL ARTAMENKO 9 30 2 00 <br /> Printed by J J KELLER a ASSOCIATES INC 12-BLS-05 Rev 12198 <br /> Neenah WI 54957.0368 ORIGINAL- RETURN TO GENERATOR <br />