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Environmental Protection Agency <br /> OM8 No.2050-0039(Expires Agency <br /> ) See Instructions on back of page 6. Department of Toxic Substances Cornrt <br /> tYPe. Form designed for�on*lite(12-pitch)typewriter. Sacramento,California <br /> t 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFESTof <br /> 3. Generator's Name and Mailing Address <br /> A. tate anifest Doc enc Niimbe <br /> 36200 1 <br /> 3 ULTRAMAR, INC. <br /> 3 B. State Generator's,ID <br /> 525 West Third Street, Hanford , CA. 93230 <br /> co <br /> 4. Generator's Phone ( ) <br /> ji <br /> 0 5. Transporter 1 Company ame <br /> 6. US EPA ID Number C. Stilt ra p er I <br /> O <br /> D] <br /> D. Tronsporter's Phone <br /> J <br /> QTransporter mpany ame 's -.m%� ._ _-_ - }. State Transporter's ID <br /> F. TransporteePhone q <br />"n Q 9. Designated Facility Nome and Site Address 10. US EPA ID Number G, State Facility's ID <br /> Z <br />. )O H & H SHIP SERVICE COMPANY <br />�a220 CHINA BASIN/TERRY FRANCOIS H. Facility's one- <br /> J <br /> 1Y ontainers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) ' <br /> Z No. Type Quantity Wt/Vol 1. Wash Number ...,<. <br />�2 a Sta1e 1 <br /> 77 F- RESIDUE GASOLINE TANH <br /> 3 GEPA/.CSC <br /> r; E NON-RCRA HAZARDOUS WASTE 'SOLID 4 0 .,1 P 0 9 0 0 0: F ... � <br /> o <br /> co <br /> N R EPA/[)iheY� <br /> A <br /> c5 T C. Strtte <br /> w O <br /> R ERA/Chher <br /> M d. Stag ;.- <br /> Z ' <br /> W �u <br /> U EPA/Other <br /> 1. Addthc*tat NsaipCrona far Morterials!,+*d Above K. Handling Codes for Wastes Listed Above <br /> w MI . 12,00,1 Callon s et tank 1a4t contain`ng p.1 >1, <br /> gasA i inert w�.th dry ice for salmi •, <br /> -tian _ a. <br /> J <br /> t`an rt a <br /> z PROSUt U4687 ° <br /> O 15, Special Handling Instructions and Additional Information <br /> F <br /> Z JOB #15484 JOB SITE: BEACON STATION, #502 <br /> W 24 Hr. Emergency Contact: H & H #(415) 543-4835 35 North Cherokee <br /> t— <br /> APPROPRIATE PR <br /> 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, <br /> Qpacked;marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> V <br /> If 1 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 <br /> T 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 <br /> CL. 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 <br /> N waste management method that is available to me and that I can afford. <br /> MotX Day Year <br /> OPrinted T SePe Name <br /> f� -\J \V1 <br /> V + s <br /> Z R 17. Transporter 1 Acknowled ement of Re t of Materials <br /> LUA Printed/Typed Nome Signature Month Day Year <br /> � s ROBERT M. BREWSTER FQ <br /> W P <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W i Printed/Typed Name Signature 7 <br /> Month Day Year <br /> LL E <br /> Q R <br /> W 19. Discrepancy Indication Space <br /> V <br /> Q F <br /> V A <br /> C <br /> Z I 1 <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature JtMonth �7Dcy�y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (9/ (Generators who submit hazardous waste for transport out4f-state, <br /> EPA 8700-22 l produce completed copy of this copy and send to DTSC within 30 days.) , <br /> t7 . <br />