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Please pprint or <br /> (Form desigrred or use on elite(12 pitch){ypewnter) ___[1 _ <br /> NON-HAZARDOUS Generators US EPA ID No Manifest Qac No 2 Pagel <br /> WASTE MANIFEST 02001 1of <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br /> hwy 12 lodi ,ca att;tsm <br /> 4 TVZg0r's prime( 2 ) 467-1006 <br /> 5 Transporter 1 CCo3mpany Name 6 US EPA ID Number A Transporter's Phone <br />' <br /> thrifty ..rooter - <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> w 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone <br /> 4 znviro tec :r <br /> y 2480 athens avem /a 43 <br /> - � <br /> 12 Containers 13 14 " <br /> ,z 11 Waste Shipping Name and Description Total Unit fK ' <br /> No Type Quantity WI/Vol r <br /> x a ;xn <br /> - non haz waste lzquid nos 001 tt <br /> waste water 't <br /> t` G b {k <br /> k E <br /> N <br /> E <br /> R <br /> k A c y <br /> `r T <br /> AA � <br />' R f <br /> R t <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> puree water from tank <br /> e 15 Special Handling Instructions and Additional Information <br /> emerg abco troy w. 916--826-3803 <br /> 12, <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above on this manifest are not subject to federal reguiations for reporting proper disposal of Hazardous Waste <br />' x Printed(Typed Name Signature Month Day Year <br /> r R 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> A nted/Typed Nam Sin urs Month Day Year <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br />' T Pnntedrryped Name Signature Month pay Year - <br /> f"4 R J <br /> 19 Discrepancy Indication Space I <br /> a " <br /> F ° <br />' 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 nt wed Name S e y Month oay Year <br /> Printed by J J KELLER&ASSOCIATES INC <br /> Neenah WI 54957-0368 12-BLS-05 Rem 12198 <br /> ORIGINAL-RETURN TO GENERATOR <br />