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1 <br /> Please prtn[or tyke <br /> (Form designed for use on elite(12-pitch)typewriter) <br /> NON-HAZARDOUS 1 Generators US EPA ID No Manifest Doc No 2 Page t <br /> WASTE MANIFEST / 001 1 of 1 <br /> 3 Generators Name and Mailing Address <br /> Cheveron <br />' hwy 12 lodi , Ca <br /> J, 4 Generators Phone( 209) 467-1006 att; tim <br /> kt <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> thrifty rooter n/a 673--8201 <br />' 7 Transporter Company Name a US EPA ID Number 9 Transporter's Phone <br /> }'Y <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone <br /> lnviro tec ,tf <br /> �-� 2480 athens ave <br /> Qln . ca 9564B /A 41 _ ry�! <br /> 11 Waste Shipping Name and Description Containers 13 14 <br /> piton Total Unit �yY <br /> No I Type Quantity FWt/VoI Y <br /> 43KtF <br /> a a <br /> non haz waste liquid nos ? i <br /> y waste water 001 tt kA, Q47 <br /> G b <br /> V E , <br /> i� N <br /> E <br /> A cY <br /> T <br /> i O Pki <br /> rtt <br /> i R <br /> d <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br /> purge water from tAnk <br /> µ <br /> ;r 15 Special Handling Instructions and Additional Information <br /> emerg abco troy w. 916=826-3803 nh <br /> t <br /> 16 GENERATOR S CERTIFICATION I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste j <br /> i PnntedrTyped Name Signature Month Day Year `Y`! <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R ^a <br /> A edlTyped Nam Si re Month Day Year ` <br /> N <br /> P <br /> QR 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> <ti T Printed/Typed Name Signature Month Day Year ,} <br /> R _ <br /> 19 Discrepancy Indication Space e <br /> F <br /> A <br />' C <br /> r 20 Factlity Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> Y <br /> Printed/Typed Name -S ature Month Day Year <br /> bill arta <br /> Pnrded by J J KELLER&ASSOCIATES INC 12-BLS-05 Rev 1219$ <br /> Neenah WI 54957-0368 ORIGINAL- RETURN TO GENERATOR <br />