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Ploase print ar type <br /> (Form designed for use an side(12 pdth)typewriter) <br /> NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Page t <br /> WASTE MANIFEST n/a 001 1 of 1 <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br /> hwy 12 lode , ca <br /> 4 Generators Phone( 209) 467-1006 att r tim -, <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone ; <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> N <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> 4ytil <br /> invzro tec M, <br /> ' 2480 athens ave . <br /> =e- <br /> lincoln, ca 95648 n/a 434-0211 <br /> `t= 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total <br /> (� <br /> it <br /> No I Type Quantity WtNol ` <br /> a non haz waste liquid nos <br /> I' waste water 0001 t cf c n5 <br /> .r G b <br /> N non haz waste liquid nos <br /> Ike R waste water <br /> �r <br /> A <br /> T a <br /> `w O <br /> IRq� fi d rte, <br /> D Additional Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above , <br /> purge water from tanks <br /> 15 Special Handling Instructions and Additional Information <br /> emerg abco troy w 916-826-3803 <br /> l Y <br /> 4 <br /> t <br /> 1� w <br /> f <br /> rk <br /> LL 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 h <br /> v T rl <br /> PnntedlTyped Name Signature Month Day Year _ <br /> " T 17 Transporter 1 Acknowledgement of Receipt of Matenals <br />'G' A Pnnyped Name Sign it March Day� Year <br /> A' S <br /> P ' <br /> a <br /> OR 18 Transporter 2 Acknowledgement of Receipt of Materials e <br /> E Printed/Typed Name Signature Month Day Year 5 <br /> R - <br /> 19 Discrepancy Indication Space <br />'£ F <br /> A <br /> C <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of waste matenals covered by this manifest except as noted to Item <br /> PnntedlTyped Name Ignature _ M oaf, Year <br />' Printed by J J KELLER&A=CIATES INC <br /> Neenah,WI 54957-03118 12-BLS-05 Rev 12198 <br /> ORIGINAL-RETURN TO GENERATOR <br />