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1i <br /> State of Colifomio—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(6xires 93496) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Pkase prim or typo Form deWned for use on eke(12prtch)fypewrrler Sacramento,California <br /> 1 Generator's US EPA tD No Manifest Document No 2 Page 1 Informafion m the shaded areas i <br /> UNIFORM HAZARDOUS t4 is not required by Federal taw < <br /> WASTE MANIFEST � 0 s tWill 1 3 F of ' <br /> 3 Generator's Name and Mailing Address 4` A State Manifest Document Number ` <br /> 10952279 ,90 <br /> 8 State Generators ID <br /> co 4 Gener's <br /> ratoPh )f/ <br /> in one ! i <br /> 9 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter's ID Coo ! <br /> oD <br /> E7t•V IROPUR VEST CORP. G AlF G $ 0 G 1 '.'16 5 9 D Transporter s Phone 4 G 6 <br /> 1i <br /> Q7 Transporter 2 Company Name 8 US EPA ID Number E State Transporters ID <br /> U i <br /> Q F Transporters Phone <br /> Z 9 Des, Hated Facility Name and Site Address 10 US EPA 1D Number G State FociiWs ID <br /> PRG PATTERS N, INC. C 31 11 61 71 81 # <br /> 7 'i 13331 N. Ma. 33 H Facility's Phone, t p <br /> PATTERSON, CA. 95363 1 ClAlDI 01 81 31 11 61 61 71218 800 834-444. <br /> Z 11 US DOT Description('including Proper Shipping Name Hazard ClassN Contoen and ID Number) y 13 Total 14 Unit 1 <br /> No T Qu ste NY <br /> Wt/Yol # Wareriber <br /> 3 Lstale 223 <br /> 1ON RCRA HAZARDOUS WASTE LIQUID 2EPA,Ofiter 1 � <br />� o E C I TIT G <br /> coo N b Stage { <br /> N E EPA/Other t <br /> R <br /> ego T c e ry t <br /> I <br /> R er EPA/Odrj <br /> w R - � <br /> Z of State <br /> U <br /> EPA/Other <br /> LLI <br /> � I <br /> J Additional Descriptions for Materials toted Above K Handling Codes for Waste Listed AboveIk a <br /> l ,! <br /> LU <br /> WATER & OIL <br /> c of <br /> Z ` <br /> 0 15 S mal Handlon Instructions and Additional Information i <br /> a Z °`ER. long CONTACT: PRC #1—(800)-874--A444 I <br /> Z 24 hR. MRG£.WC'2 RESPONSE: CHEM TEL INC. #1—(800)--255-3924 <br /> 1J' A.PP90FRIATE RROTECTIFE CLOTHING 6 RESPIRATOR. <br /> x i <br /> t- <br /> 16 GENERATOR'S CERTIRCATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping nine and are ckmwfwd <br /> U packed marked and labeled and are to all respects in proper condition for transport by highway according to applicable international and national governments <br /> regulation { <br /> !! <br /> If I 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 to be i <br /> p, economically practicable and that 1 have selected the practicable method of treatment,storage or disposal currently available to me which minimizes the present and future <br /> V) threat to human health and the environment OR if 1 am a small quantity generator I have made a good forth effort to minimae my waste generation and select the best <br /> O <br /> waste management method that is avamiable to me and that I can afford <br /> Panted/Jypafi Name / Sigrrahura ! ' Month ear <br /> Z T 17 Transporter 1 Acknowled a ofof-Recem of Materials <br /> LU <br /> _ <br /> R _ _ <br /> N Parried/Ty�edNar /t Signature` F ! (r� <br /> 6@ !VS <br /> LU S r L h <br /> w O 18 Trans rter 2 Acknowledgement of Receipt of Motenals / 1 <br /> O T Printed/Typed Name <br /> Signaturo Month Day Year <br /> E <br /> R <br /> N19 Discrepancy Indication Space <br /> Q F <br /> U A <br /> Z C <br /> I !I <br /> 10 ` Y <br /> l 20 Facmi Owner or Operator Certification of receipt of hazardous matenals covered this manifest except as iroted in Item 19 <br /> YPrinted/Typed Name Sigitaturo MonthDay Year <br /> i <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC B022A (9/94) Yellow GENERATOR RETAINS <br /> EPA 8700--22 <br /> r <br />