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rimental Protection Agency <br />' .0 2050-0039(Expires 9 30 991 See Instructions on back of pa e 6 Department of Toxic Substances Control <br /> r. Form designed for use on ithis(12 pitch)ly---ver ler Sacramento California <br /> UNIFORM HAZARDOUS 1 v-.. sraior s US EPA ED No Manifest Document No, 2 Page 1 Information in the shaded areas <br /> is not required by Federal law <br /> W STE MANIFEST L ' Z '� (� S of <br /> 3 Generators Name c;Ad Mailing Address Cjj iim �P^ A State Manifest Document Numbe21154430 w O <br /> 0C)T-O0 0 B 511.Generator's ID <br />' ^ 4 Generator s Phone( )SO R ZL f y, r- <br /> 5 Transparfor 1 Compp y Nome 6 US EPA ED Number C State Transporter s ID[Reserved I jilt"'i aril <br /> 0° MERIGAN VALLEY WAs fF OIL. , A L Q t) 0 8 2 7 8 7 � D Trans 800-732-4645 <br /> p porter s Phone <br /> L7 Transporter 2 Company Name 8 US EPA ID Number E Slate Transporter s ED[Reserved I <br /> Transporter's Phone <br />'! < <br /> V <br /> sSf sr c"szszt S tVtZm l�' {°�✓' 10 US EPA ID Number G <br /> Q stalyiDQ )d 9 Q 13 1 a <br /> oZ O CLAUS ROADr.thy } !� ^ H Facility <br /> /s��Phone q p <br /> 0 1VERBANK.GA 96.36 A I_ � V V 1 0 8 0 � 2W4M-81537 <br /> J <br /> Q 12 Containers 13 Total lI Uno <br /> l j 11 US DOT Description(including Proper Shipping Name,Hazard Class and ED Number) No T Quant WIN01 <br /> I Waste Number Sir <br /> s r ICON-RCRA HAZAROOUS WASTE LIQUID state 221 } <br /> 3 <br /> (OILY WATER ) 0 0 1 T T I O F EPA/Other <br /> 0 E <br /> G 5 + i ;;" <br /> b slate <br /> m E <br /> EPA/Other <br /> 4 A c S Slate w - <br />' o T <br /> 0 r0 r e <br /> r , EPA/Other <br />' ur�r d State- s- <br /> Z <br /> J Additional Descriptions for Materials Listed Above K Handling Codes For Wastes Listed Above ✓y 1l..+ <br /> OWY WATER ` a 01 - 1 - b --_ it _ _ . ,6 <br /> N <br /> w _ <br /> .i c d <br /> J <br /> 0 15 Special Handling Instructions and Additional information <br /> a OLOVES <br /> ,Z 't CMERGENCY MONO 209-067-88'W <br /> .16 GENERATOR'S CERTIFICATION 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name rind'are classified packed <br /> marked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable international and national government regulations <br /> � t , <br /> if I am a large quanhy 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 economical <br /> 4 - practicable and that l hove selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human 62 ' <br /> rn and the environment,OR,if I am a small quantity generator I have made a good 6th effort to minimize my waste generation and select the best wade monagement method that is <br /> Oavailable to me and that I can afford + ',i • ' <br /> UU <br /> inted/Typed Nome / Signature ' �^ 4- '� Month Day Year <br /> s�11�YLb b � . ��11+ ��.� I •.,.. 1 LO <br /> W 17 Transporter 1 Ad nowled ement of Receipt of Materials <br /> Printed/Typed Name Signature s ~Month Day Year <br /> LLI P <br /> -,x No <br /> si 0 T8 Trans rter 2 Acknowledgement of Receipt of Materials <br /> OT Printed/Typed Name /i Signature Month Day Year <br /> N E <br /> Q R <br /> t LJ 19 Discreponcy Indication Space <br /> Z F <br /> A <br /> C <br /> t F 20 Facility Owner or Operator Certification of receipt of hazardous molenaIs covered b chis manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> i <br />' DO NOT WRITE BELOW THIS LINE <br /> i <br /> DTSC 8022A(1/99) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br /> r+ <br /> Li <br />