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1 <br /> Please pant or type <br /> (Form designedfar use on elite(12 pitch)tylxmnier f <br /> NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Pagel <br /> WASTE MANIFEST n/a 0001 1°fl <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br />' y hwy 12 lodi ,ca att; tim <br /> 4 Generatckoda tg is a 2 0)9 467 1006 <br /> i <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> 3 thrifty rooter n/a 673-8201 r <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporters Phone <br /> Si <br /> x 9 Designatrff clit�f.f f�mitig�5ite Address 10 US EPA ID Number C Facility Phone <br /> U� <br /> , 2480 athjens ave F <br /> Lincoln, ca 95648 n/a 434-0211 <br /> 2 11 Waste Shopping Name and Description 12 Containers 13' Total 14 a.i _ <br /> No I Type Quantity W1/Vol w <br /> _ a 1 <br /> non haz waste liquid nos <br />' waste water 001 t <br /> G b <br /> I E �z <br /> ' N <br /> E <br /> r R <br /> A c <br /> T <br /> 0 <br /> I� R �a { <br /> d <br />' D Additional Descriptions for Matenals Listed Above E Handling Codes for Wastes Listed Above <br /> v, <br /> purge water from tank <br /> 15 Special Handling Instructions and Additional Information <br /> emerg; abco troy w. 916-826-3803 <br /> V- <br /> V <br /> 16 GENERATORS CERTIFICATION I certify the materials descnbep above on this manifest are not subject to fed tions for reporting proper disposal of Hazardous Waste <br /> Print ed Name re Month Day Year <br /> `r J <br /> k <br /> ' RT 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> r A Printed/Typed Name o nature onfh Day Year ' <br /> N o <br /> S <br /> P <br /> R 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> f E Printed/Typed Name Signature Month Day Year <br /> R <br /> 19 Discrepancy Indication Space <br /> 3' F <br /> A <br /> C <br /> I <br /> 20 Facility Owner or Operator Certification of receipt of waste materials covered by this manifest except as noted in Item 19 <br /> I Y ' r <br /> Pnn ed Name Signature Pr � Month nay Year <br /> I Printed by J J KELLER$ASSOCIATES INC 12-BLS-05 Rev 12/98 <br /> Neenah WI 54957-0368 <br /> ORIGINAL- RETURN TO GENERATOR <br />