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I <br /> Please print or <br /> (Form designed for usa on elite(12 pitch)typewriter) <br />' NON-HAZARDOUS 1 Generator's US EPA ID No Manifest Doc No 2 Pagel <br /> WASTE MANIFEST n/a 40001 1 011 <br /> 3 Generators Name and Mailing Address <br /> cheveron <br /> hwy 12 lodi. , ca att; ; tim <br /> 1 <br /> 17 <br /> a 4 Generators Phone( 209 467 1996 <br /> ri <br /> _Y 5 Transporter 1 Company Name 6 US EPA ID Number A Transporters Phone <br />' ,' thrifty rooter n/a 673-1923 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporters Phone k <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone 4k <br /> 'Y snviro tec <br /> 2480 athens ave � < <br /> t lincoln, ca 95648 as/a 434-0211 <br />'tTM 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit <br /> No Type Quantity 1Wt/VQI <br /> a non haz waste liquid nos 1000 gal ., <br /> waste water 001 tt <br /> E b <br /> F E , <br /> R <br /> it A c <br /> i1 U 4 <br /> 1 r` R d <br /> i%5 Yt 1 <br /> Y <br /> S <br />' <br /> 1 <br /> ) Additional Descriptions for Matenals Listed Above E Handling Codes for Wastes Listed Above <br /> purge water from tank <br /> I <br /> 15 Special Handling Instructions and Additional Information <br /> emerg; abco troy w. . 916-826-3803 <br /> �Sr <br /> k tiY <br /> 16 GENERATOR'S CERTIFICATION I certify the materials descnbed above on this manifest are not subtact to federal regulations for reporting proper disposal of Hazardous Waste <br /> Pnnied/Typed Name Signature Month pay Year <br /> fi <br /> TR 17 Transporter 1 Acknowledge nt of Receipt of Materials f <br /> A yped Name Sign Mon - r y` <br /> r N G= r <br /> P r <br /> j O 18 Transporter 2 Acknowledgement of Receipt of Materials F+, <br /> i T Pnntedrryped Name Signature Month Day Year 1 <br /> * E <br /> r.y R <br /> 19 Discrepancy Indication Space <br /> F <br /> tai A <br />' i 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 /> r <br /> oe <br />' Y e ed Name St a ur Mo r r <br />' Nee ad by I J KEt0Eq g or <br /> 5 INC 12-BLS-05 Rev 12/98 <br /> Neenah WI 54957 0368 <br /> ORIGINAL --RETURN TO GENERATOR <br />