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Please print Of lype <br /> {Form esigned for use on elle(12-pitchy typewriter) <br /> ITNON-HAZARDOUS 1 Generators US EPA ID No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST n/a 0001 1 of 1 <br /> 3 Generator's Name and Mailing Address <br /> cheveron <br /> hwy 12 lodi ,ca att, tim <br /> 4 Generators hone( ) 467-1006 <br /> ,u,r <br /> t}, 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone ; <br /> thrifty rooter, �� <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> x" <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility's Phone 5 <br /> inviro tec <br /> I 2480 athens ave t <br /> „l lincoln, ca 95648n1a _ r <br /> 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit 3'.rV <br /> ' No I Type Quantity Wt(Vol <br /> ' a non haz waste .liquid nos 001 tt <br /> waste water <br /> }d G b <br /> E <br /> N r <br /> E <br /> yFr A c ;+ <br /> ; T <br /> R `{ <br /> "t d ` sg <br /> D Adddionat Descriptions for Materials Listed Above E Handling Codes for Wastes Listed Above <br />�c <br /> purge water from tank <br /> 15 Special Handling Instructions and Additional Information <br /> emerg abco troy w. 916--826-3803 <br /> Y <br /> l' <br /> SNS. <br /> 16 GENERATOR'S CERTIFICATION I certify the materials described above on this manifest are not subject to federal regulations for reporhng proper disposal of Hazardous waste i <br /> U <br /> Printed/Typed Name Signature Month Day Year .v <br /> � <br /> r,. <br /> T 17 Transporter 1 Acknowledgement of Receipt of Matenals <br /> qA A ledfrypedName Si a r Month Day Year <br /> S <br /> P <br /> s O 18 Transporter 2 Acknowledgement of Receipt of Materials , <br /> TPrinted/Typed Name Signature Month Day Year I fr <br /> irk E <br /> R <br /> c"- 19 Discrepancy Indication Space <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 Printed/Typed Name Signature <br /> . r. nth Day Year <br /> bill c� <br /> 00 <br />' Printed by J J KELLER a ASSOCIATES INC 12-BLS-05 Rev 2/98 <br /> Neenah W1 54957-0368 <br /> ORIGINAL-RETURN TO GENERATOR <br />