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�rr,,,, <br /> $lore of Ca6farnro—EnnranmMlal PYaIeQlen Agency <br /> Perm Appraved OMB No 2050-00`d41E>flsrres 4-30 991 St3B IT1StfuCtlCl#s an �?de�( of page b. Department of Toxic Substances California C¢nlra <br /> Please print or type Farm designed For uta on his 112 pdr Sa�¢ment¢,G¢Idornra <br /> 1 Generolor's U5 EPA FD No Man+fe t Document Na 2 Page 1 lnformatian m the sfodaa oreas <br /> I UNIFORM HAZARDOUS (� C. s not required 6y Federal Inas <br /> WASTE MANIFEST A p 8 � .7 ! <br /> • of <br /> 3 Generator a Name and M4thng Address ' Q u A. State Mc m6st Document Numbs' 21653098 <br /> PU e0k 8 slate General is ID <br /> W1 <br /> d Generoror's Phone <br /> 4i WM57 � h r CQ q--A3J-5I <br /> N 5 Transporter i Company Name b US EPA IQ Number C state Transparhr s ID Reserved.} <br /> co f4f4.t#tOA€MVALLEY 1A`sxi OILA v 0V d r tt r s D Transport.r's Pha,w esu-t t irr <br /> 0 <br /> rA 7 Tromparter 2 Company flame 8 US EPA Id Number E slate Tronsparhsr'a 0(R�a grrtd} <br /> F Transporters Phone <br />' U a ;- 10 US EPA ID Num6ar G sta�s Faalllr�i I� L U a 1 t <br /> `4i 9 r lfl#�dN�r&0- i14+A 0 eft <br /> III <br /> cy) 53000 CLAUS ROAD H PaciltiyA -aG34-8181 <br /> LO IRWER11ANK, GA 95367 _ t} 0 U 1 3 It7 t. 1 <br /> Q12 Cantrnrnrs 13 Total 14 Und <br /> V <br /> 11 US DOT Deicription itncluding Proper Shipping Name Hazard Class and ID Numberl No T Quontly Wt/vol I Waste Number <br /> Z a NON RCRA HAZARDOU-5 WASTE I_IQUIO sial. 22 <br />' z ( OILY WATER ) U O t t T r C' EPA/ON.r <br /> 3 G <br /> E ' <br /> m E 6 EzA/Other <br /> I <br /> i v A $Iota- < <br /> y m n c EPA/Olher <br /> stale <br /> L W a <br /> W <br /> Z EPA/Other <br /> w <br /> V <br />' w !C Hattditng Codas fa Wastes lasted Above <br /> J Adddtonaf pescripttons for Materials Lahr#Abase -!�y)� b <br /> O1N WATFR a f <br /> O 1 <br /> to <br /> Lu c d <br /> oc <br />' 1 < <br /> a <br /> Z I5 Special Handling Inilruchans and AddiltonaE Infarrnaton <br /> GLOVES <br />' Z EMERGENCY PHONE 209-648743857 r <br /> 16 GENERATOR'S CEltTOCATION 1 hereby dedore that the captenis of this consignment are fully and accurately described above oy proper sh'ppmg nae and are dassthed pacsod <br /> < marked and ia6sied and tat in all impede in proper coaditioe For transport by highvray according to opplica6le mlemotiartal and nohonai m <br /> government regulations <br />' < V <br /> If I nm a large quMhty geitaYaser t certify that I have a propram In prate to'educt Ifs volume and toxicity of waste generated iq If+e degree l fora determined to be human hooll <br /> i d practicable and ifat I=selected Ilse roctico61e method of treatment storage or dtsposai cue ntly available to me Which minimizes tke present and future gain to human health <br /> pp ad Fadh eiFan hs msnmtl>e waste generotson and aaleH the hes!.mate management metnod Ihat .s <br /> I and the Mwronment OR It I am a small quardity gteneralor,S have mode a se my <br /> ovadable to me and that I can afford <br /> ry p 1!2 <br /> ! h a ^t! a <br />' V <br /> "Prip adZ <br /> t LU T 17 Trans ter l Acknowiedgemery of Recst of Materials _ / /�, - <br /> Md/TyQacf Natrle, � Srena � [ t 6 f ca <br /> L w P <br /> w 0 1B Trona iter 2 Acknowledgement of Roca i of Matanala Mundt Dar Yet <br /> a i Prtntad/Typed Name Signature <br /> vt p <br />' U I9 Dacroponcyr Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> ! I <br /> I 20 Facility Owner w O 111 1111 Corhhcah 1, of'ecu t at hazardaus motenals caveved lfu manifest nce t as mol m tam Month Dayti Ym <br /> T Printed/Typed Npme ' Signawn <br /> DO NOT WRITE BELOW THIS lIr4E <br /> l <br /> DTSC 8022A f1/991 <br /> PPA 8700-22 <br />