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/,-,�IYPe- r,�a—EnvironmeMaE Protection Agency OMB050-W39(Expires 9-30-94) See Instructions on back of page 6. Department of Toxic Substances COP Form designed for use on elite(12-pitch)typewr;w- Sacramento,Californto UNIFORM HAZARDOUS 1. Generator's US EPA ID No, Manifest Document No. . 2. Page 1 Information in the shaded areas is not required by Federal law. WASTE MANIFEST ICIAIL19131010161311L8171 5 0 2 0 1 of 1 3. Generator's Name and Mailing Address A. State Manifest Document Number ��++ ULTRAMAR; INC. 9�U0 0..ta 525 West Third Street, Hanford, CA, 93230 S. State Generators ID, h 4. Generafor'sPhone (209) 583-3347 O 5. Transporter 1 Company.Name 6. US EPA ID Number C. State Transporter SAP. .000932°' �" "DID 10 10 14 17 17 1111 jr, jjq' . Transportee f frons a .1 H & H Sha Service Com an . C• A543 7. Transporter 2 Company Name ',.8:'US EPA ID Number -E, State Transporter's 10 .s a :t U F., 1'ranspartei's,Rhone- "� V Q 9- Designated Facility Name and Site Address 10_ US EPA ID Number- G. State Fa4ilitys ID H & H SHIP SERVICE COMPANY _ C A D} 0 0 .4 ' 7 1 $ a 220 CHINA BASIN/TERRY FRANCOIS H. Facilitys Phone 'Nq ' F< 4 SAN FRANCISCO, CA. 94107C A A Q 0 4 7 7 1 1 6 8 (415) 5'43-4:835 `J 11 12. Containers 13. Total 14. Unit 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) No. Type Quantity Wt/Vot 1. Waste Numbat r a.Rtare RESIDUE GASOLINE TANK n 3 G NON-RCRA HAZARDOUS WASTE SOLID Q ;Q 1 T P P. EPA/0169T TR r EP'AlCNIotflet v A X31 oT c State .... 00 0 R EPA/Others:..� 'a,'� zd. ` state L U EPA/i 1tar 1."Addifianol Destriptkm$fcsr Materials listed Above "N K, Handling Codes for nt4sfies`Listed Above' , a I MP'1 1Q: A q pUnk inertstr`rtwxt x i-f t 1CdAtar N , a, b raAg AFTDr O 15. Special Handling Instructions and Additional Information a JOB #15484. JOB SITE: BEACON STATION, #502 Z 24 Hr. Emergency Contact: H & H #(415) 5434835 35 North Cherokee , U' APPROPRIATE PROTECTIVE CLOTHING AND RESPIRATOR Lodi, California x 16. GENERATOR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, J packed,marked,and labeled,and ore in all respects in proper condition for transport b highway according to a lica !e international and national government,regulations. P Pe P P P Y g aY g PP V If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best 77. waste management method nt is available To me and that 1 can,afford. ' 0 t •�/'� Month D Year Printed a Name l � Sign re 1 ► 1 � � Day } " t M. � � � 0 2 2 8 9 5 T 17, Transporter 1 Acknowled ement of Recti t o Materials Ly R Si tore r Month, Day = Year, C7 " Printed f ft .gneH. 12FESE g � .,�...�. . S 0 2 2 8 9 :5 lL P 0 18. Transporter 2 Acknowledgement of Receipt of Materials W T Printed/Typed Name gnahsre Month Day Year U- e O R N19. Discrepancy Indication Space Q F V A ZC I _ E 20. Facility Owner or Operator Certification of receipt of hozardous materials covered b this manifest except as noted in Item 19. Printed/Typed Name Signature Month Day Z S DO NOT WIiITE BELOW THIS LINE. k Yellow: TSDF SENDS TM5.C'6PY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (9/93) (Generators who submit hazardous waste for transport out-of-state` i j EPA 6700_22 produce completer} copy of this copy and send to DTSC within 30 days.)