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Slate of Califomie-death and Welfare Agency Department es Heath Service <br /> Form Approved OMB No.2050.- D39(Expires 9-30-W ♦� Toxic Substances Control Division <br /> Please rrint or type. (Form designed for use"&life' itch typewriter). instructions on the `iIC Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator&US EPA ID No. Manifest 2. Page 1 Information in the shaded areae <br /> Document No. <br /> WASTE MANIFEST 2 15 R 1 711 of Is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State ALnyesl,pggprp ,NVr <br /> Cal Dept. of Military OMS#24, yV(WSJ!U�ILJ:11 � ly <br /> 8010 South Airport Way, Stockton, CA 95206 B. State G"aretors n <br /> 4. Generator's Phone(209) 9B2-4416 <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tra isporter's ID <br /> D. Tranaporter'a Phone — — <br /> Placer Tractor Service C D 9 8 2 0 0 <br /> ne. US EPA ID Number E. State Transporter'&ID <br /> m 7. Transporter 2 Company Name <br /> F. Transportar's Phone <br /> 9. Designated Facility Name and She Address 10. US EPA ID Number G. State Fecllitya !/ <br /> Refinery Services <br /> -il Q 13331 N. Highway 33 ' tone <br /> Patterson CA 95363 - <br /> 12. Contain 13. Total 14. I. <br /> US DOT Description(including Proper Shipping Name,Hazard Claes,end ID Number) Quantity Una Waste No. <br /> LL 1 t. No. Type We/vol <br /> \J <br /> U <br /> e State <br /> 7 2 EP / er <br /> 0 e California Regulatgd klaratp Only a I nI I TI rp <br /> State <br /> E b. <br /> of R <br /> 4 A EPA/Other <br /> s� T <br /> Rc Slate <br /> EPA/D1Mf <br /> �Wl- d Stale <br /> gZj EPA/OIMr <br /> U <br /> iV) J. Additional DesviDtione for Materials Listed Above K. Handling Codes for West"Listed Above <br /> 6 OR-1Q. <br /> b. <br /> to Waste Oil/Water/Rinseate <br /> �. d. <br /> ZZip <br /> r 15. Special Handling Instructions and Additional Information Ihning 'e <br /> End 01 Commercial Drive <br /> W r Gloves Bakersfield CA 93308 <br /> /— CAp 98nRR3177 805-323.3171 <br /> J <br /> V 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare Ih tae contents of this con �pnmenl are lolly and accurately described above by proper shipping name <br /> J <br /> � <br /> 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 /> d national government regulations. <br /> W <br /> If I em a large quantity generator.I certify have I have a program in place io reduce the volume and storage, <br /> or y of os ate generated to the degree ee 1 have minimizes <br /> determined <br /> U pr he economically hroati to hu and that 1 have selected the practicable m tr"storage,or a disposal currently available to me which minimizes the <br /> � present and future&areal to human health and the environmem;OR.if a small quen enerator,1 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 IXan afford. <br /> W Printed/Typed Name ' nature eyJ Month Day Year <br /> W <br /> wT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Month Do IA-4,1YearS le Z - <br /> 2 A Printed/ ypad Name ; /+� <br /> o )LA V\C..�'v.. ' <br /> W O 13. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> U T <br /> E "This manifest <br /> 7989 , or manifest documentation dates required <br /> 19. Discrepancy IntlitMeSA�dry t <br /> F <br /> A <br /> D <br /> I GIBSON OI 8 EFINING CO. INC <br /> 1 20. Facility Owner or Operator Cereticatbn of receipt hazardous materials covered by this manifest a Capt as n em 19. <br /> T <br /> Printed/Typed Ze <br /> Signature th <br /> DHS 3022 A(1/33) Do Not Write Below This ym ; TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> EPA 3700-22 <br /> (Rev.9-33)Previous editions are obsolete. To: P.O. Box 3000,Socrafnenlo, CA 95812 <br />