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Ste,¢of Celifomis–Health and Welfare Agency « See Instructions on of Pag I parte oI Health Service <br /> Form Approved OMB No.2050--0039(Expires 9-3i and Front Ot e 7 m Substances Control DMslc <br /> Please print or type. (Foran designed(o/use an elite(12-pitch typawnfer). Sacramento,CnlBor, <br /> UNIFORM HAZARDOUS 1 1. Generator's US EPA 10 No. Manifest 2. Page Information in the shaded areas <br /> WASTE MANIFEST CAI 0 0 0 0 6 2 5 8 0 0 0 a0 Ont0 1of 1 <br /> is not repaired by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Dccttrneed Number <br /> HERMAN & HELEN'S MARINA, INC. 90263650 <br /> 15135 W. EIGHT MILE ROAD, STOCKTON, CA 95219 e. Slate Gra alues to <br /> 4. Generator's Phone(209) 951-4634 <br /> e 5. Transporter t Company Name 8. US EPA ID Number C State Transporters to`:,200692 <br /> m> WARREN E. GOMES EXCAVATING, INC. CAD 0 7 6 5 5 7 3 7 0 D• TM'"apOffereohO1e 707-374-2881 <br /> N <br /> 'n 7. Transporter 2 Company Name B. US EPA ID Number E..r Stals Tutuportarn ID,_'. <br /> moF.,Traroportera Ph.. _. <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA 10 Number G.blots fadlity'a ID <br /> ERICKSON, INC. <br /> a255 Parr Blvd. , Richmond, CA 94801 It Facet'a PhonB <br /> L1)¢ c_j jq <br /> 12. Container 13. Total 14, L <br /> Co 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No- Type Wt/Vol <br /> M N <br /> Q l <br /> Of a. State <br /> N= G WASTE EMPTY STORAGE TANK - 512 <br /> p I E NON—RCRA HAZARDOUS WASTE SOLID EPA/Cthee <br /> 3 N01011 lip— 110101010 P <br /> E b. State - <br /> " R WASTE EMPTY STORAGE TANK 512 <br /> NTD NON-RCRA HAZARDOUS WASTE SOLID 01011 T P13101010 P EPANONE <br /> a R c State <br /> 8 WASTE EMPTY STORAGE TANK <br /> NON-RCRA HAZARDOUS WASTE SOLID EPA/omw <br /> 11101010 P <br /> rd. Slate.. <br /> Z <br /> w <br /> U EPA/Other <br /> W <br /> la J Additiaul Descriptions for Metariale Listed K <br /> d r J :.yx t,�.,f r �� .y 1 ":aY sea t `� { Cod"fa Wastes Elated Above <br /> 773rww"0 2I 4 & 7423 �OlS n . 6 <br /> w 'TISNKS SAVE BEQITED�WI7Ti 20 75 OF>DRYICE TM y 4 — <br /> d.- <br /> J ,OOO GS; CAPACITY >a. _ <br /> O <br /> F 15`Special Handling Instructions and Additional Information <br /> Z KEEP AI4AY FROM SOURCES OF IGNITION. ALWAYS WEAR HARDHATS WHEN WORKING AROUND U.S.T. 'S. <br /> 24 HOUR CONTACT NAME IS JERRY MATTHEWS AT 209-951-4634 <br /> J <br /> Q 18. <br /> U <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and label".and are in all respects in proper condition for transport by highway according to applicable international and <br /> D_ rational goverreaent regulations. <br /> Go <br /> If I am a large guenfity generator,1 certify that 1 have a program in place to reduce Me volume and toxicity of waste generated to the degree I have determined <br /> U to be economically practicable and that 1 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,8 I am a small guatdfy generator.I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> W Printed/Typed Name Sign a Month Day Yeer <br /> w <br /> JERRY MATTHEWS 111013101911 <br /> W <br /> w T 17. Transporter t Acknowledgement of Receipt of Materials 4-11 <br /> R <br /> < A Printed/Typed Nam" Signatu a Month Day Year <br /> N <br /> o P If 0131 Of 911 <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> m <br /> T Printed/Typed Name Signature I II Day Year <br /> Ln E 'I � l�'A <br /> 19. Discrepancy Indication Space <br /> F jAN 2 9 1992 <br /> A <br /> D ENVIRONMIENFAL i FAk TH <br /> I <br /> L 1-41 L 'I i_iJi: e Q <br /> 1 20. Facility Ownw N Operator Certification at receipt of hazardous materials covered by this mandest except as not hem 19. <br /> T It <br /> Y P e /TName Signa _ Monrlr Qay Year <br /> Li LJ <br /> DHS 8022 A(1188) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous aditione are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DA` <br /> To: P.O. Bax 3000, Sacramento, CA 95812 <br />