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State of California—Health and Welfare Agency ivisiDepartment Of Health Serwoon <br /> Form Approved OMB No 2050--0039(Expires 9 30 91) Toxic SubslControl <br /> Sacramento C©iforrn a <br /> Please print ar type (Form designed for use on ehfe(12 pitch typewriter) <br /> UNIFORM HAZARDOUS 1 Generator a US EPA ID No Man fest 2 Page t Information in the shaded areas <br /> WASTE MANIFEST L A D 9 8 4 5 y g 4 4 floo "'M1 No 5 1 of 1 to not required by Federal law <br /> 3 Generator a Name and Mailing Address G oO 4 A State Manifest D cu ent Nmber <br /> Airily. DAVE CLARK SANTA FEE tiA1LQAY CO- 8 � � 04342 <br /> 577U S. EaS;ern Ave. Los Angeles, CA. 90040 B State Generator a 10 <br /> 4 Generators Phone( ) <br /> iQy 6 Transporter t Company Name a US EPA ID Number C State Transporter s ID 10 20 70 <br /> +fiD Transporter s Phon <br /> Refirier2.es Service D 0 8 l b s 1712181209) 800-§71-4444 <br /> m7 Transporter 2 Company Name a US EPA ID Number E State Transporter a ID <br /> soF Transporter a Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility a ID <br /> Refineries :erivice <br /> H Facility s Phone <br /> `� 13331 N. HWY. 33 <br /> Patiterson CA. 95161 K; IA ip io 1b 11 11, 1616 7 12 181 (2 91 flion-6711—A444 <br /> 12 Containers 13 Total 14 <br /> Q t <br /> 1 tUS DOT Description(Including Proper Shipping Name Hazard Class and ID Number) Quantity Unit Waste No <br /> ylL , No Type WI/Vol <br /> }U allon RCRA HAZARDOUS WASTE LIQUID state ` , <br /> 1x G a G <br /> N State <br /> E b <br /> R <br /> A EPA!Other <br /> ra T <br /> NG <br /> a R c State <br /> EPA/Other <br /> to <br /> IX W d State <br /> f- <br /> w EPA/Other <br /> V Lj <br /> Uj <br /> N J Additional Descriptions for Materials 11-listedAbove K Handling Codes for Wastes Listed Above <br /> ��' e b <br /> fi <br /> PEMLEUM HYDROCARBONS APPROXI -;";&�(Jy <br /> WATER APPROX% f i d <br /> a SLUDGE APPROX% G <br /> z <br /> Q 15 Special Handling instructions and Additional Information <br /> Z WEAR GLOVES, GOGGLES &PROTECTIVE CLOTHING <br /> IN EASE OF SPILL CALL EMERGENCY RESPONES (209) 800-874--4444 OR (209) 892--6742 <br /> J <br /> 4 <br /> V 18 <br /> GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately deacnbed above by proper shipping name <br /> J and are classified packed marked and labeled and are In all respects in proper condition for transport by highway according to applicable international and <br /> a national government regulations <br /> lz It 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 <br /> 0 to be economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the <br /> 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 <br /> V generation and select the beat waste management method that is available to me end that I can afford <br /> Month DayYear <br /> ILI Printed/Typed Name Signature ! <br /> IX <br /> LAI <br /> y2j T 17 Transporter t Acknowledgement of Receipt of Materials <br /> Signature <br /> Month Day Year <br /> N Printed/Typed Name , / , / <br /> LL s .1+ v►+f l V�S 5 <br /> P LU 18 Transporter 2 Acknowledgement of Receipt of Materiels <br /> VT Printed/Typed Name Sig t e Month Oay Year <br /> E <br /> Z <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> i 20 Facility owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19 <br /> T Signature Month Dey Year <br /> y Printed/Typed Name <br /> DNS 8022 A(I 188) Do Not Write Below This Line <br /> EPA 8700--22 Blue CENERATOR SENDS 1HIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev 9 88)Previous editions are obsolete <br /> To PO Bo* 400 Sacramento, CA 95812 0400 <br />