Laserfiche WebLink
Prrasa print or type- <br /> (F <br /> ype <br /> (Form Zn, <br /> for use on elite(12-pilich)ty)Cwreer) <br />' NON-HAZARDOUS 1 Generator's US EPA 1D No Manifest Doc No 2 Page 1 <br /> WASTE MANIFEST n a 1 04001f <br /> 3 Generator s Name and Mailing Address <br /> cheveron <br /> lodi r ca <br /> 4 Generator's Phone( 209 467-1006 tim <br /> +41 5 Transporter 1 Company Name 6 US EPA ID Number A Transporter's Phone <br /> ` thrifty rooter n a 673-8201 " <br /> 7 Transporter 2 Company Name 8 US EPA ID Number B Transporter's Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone ' <br />�rr inviro tec <br /> 2480 athens ave <br /> 4 lincolnrca 94548 n/a 434-0231 <br /> 14; 11 Waste Shipping Name and Descnption 12 Containers T t I 14 <br /> Unit <br /> 41 No I Type Quantity WtNol p 1 <br /> i a x ' <br /> w, <br /> non haz waste liquid -- <br /> waste water 001 t `14 ; <br /> i� <br /> G b .,r <br /> 17 N <br /> E <br /> R .' <br /> ' A c <br /> T <br /> R <br /> d <br />', D Additional Descriptions for Materials Listed Above F Handling Codes for Wastes Listed Above <br /> purge water from tank <br /> 15 Special Handling Instructions and Additional Information <br /> V <br /> wear ppc <br /> emerg/ abco troy w 916-826--3803 <br /> U16 GENERATOR S CERTIFICATION I certify the materials described above on this manifest are not subject to tederat regulations for reporting proper disposal of Hazardous WastePrintedfTyped Name Signature Month Day Year } <br /> n <br /> rr R 17 Transporter 1 Acknowledgement of Receipt of Materials 4 <br /> A Nnted/Typed NathSr t e Month Day Year <br /> S JJG�:! • ( ��€mow <br /> ria <br /> P <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> T Pnnted/Typed Name Signature Month Day Year , <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br /> 1 <br /> IF 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 Si Month Day Year <br /> bill artamenk o <br />' <br /> Printed byJ J KE'I R&ASSOCIATES INC 12-BLS-05 Rev 2/9$ <br /> Neenah WI 54957 4368 <br /> ORIGINAL-RETURN TO GENERATOR <br />