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eafth and Welfare Agency Toxic Substances Control Division <br /> >`1 Sacramento,California <br /> s No.2050--0039(Expires 9-30.91)�. P <br /> tir0e, (Form designed for use on elite 0... l typewriter). Manifest age 1 Information in the shaded areas <br /> 3?41FORM HAZARDOUS ... t erator's U5 EPA ID No. Document No. <br /> of is not required by Federal law. <br /> WASTE MANIFEST A. State Manifest Document Number <br /> g Generator's Name end Mailing Address - - - 81979 <br /> Alex Gilliland e. state Generafora ID <br /> 3776 Grant Line Rd. Tracy, CA 95376 <br /> 4'. Generator's Phone( 20g 835-5530 <br /> 8, US EPA ID Number C. State Transporter's ID <br /> 5. Transporter 1 Company Name D. Transporter's phone <br /> Refineries Service <br /> rC E. State Transporter'a <br /> 7. Transporter 2 Company Name 8. S PA ID um er <br /> F. Transporter's Phone <br /> 6 <br /> o G. State Facility's ID <br /> j a0 9. Designated Facility Name and Site Address � 10. US EPA ID Number <br /> Refineries Service +5 <br /> H. ility's Phone <br /> C7?0 13331 N. Hwy. 33, Patterson, CA 95363 <br /> Q CAD 10 18 13 11 1616 71218 209-892-6742 <br /> Z 12. Containers 13, Total 14. I: <br /> Lo O Quantity Unit Waste.Nc. <br /> LL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type WtlVel <br /> � State <br /> tiQ a- .Hazardous Waste Liquid NOS ORM-E HA 9189 <br /> Q7 Z <br /> FPA10ther <br /> o0 EInd V T T D Da - 16 <br /> N stare <br /> E b.- <br /> O R <br /> Co A EPAIOthec'.:,_. <br /> m T <br /> v O State <br /> N r:at , <br /> v R C. .. <br /> 0 <br /> � <br /> EPA/Other-, s..,. <br /> StateCc <br /> r <br /> N d. <br /> Z EPA10ther: <br /> w <br /> U <br /> j <br /> Z is Additional Descriptions for Materiels Usied Above K..Handling Codes for Wastes Listed Above <br /> a b <br /> ie 9.g <br /> 01R ;:. <br /> Lu <br /> rinf3ate �,r s t .. -•--- `7't1 t "� i o d. <br /> Q <br /> Z TaogA <br /> O <br /> 15. Special Handling Instructions and Additions!Information <br /> Q <br /> Z <br /> w <br /> i 2 <br /> r <br /> � � v <br /> a , <br /> r U 1f3. <br /> Ir GENERATOR'S CERT(FICATIOk: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> r =d and are classified,pecked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> Nnalional.government regulations. <br /> If I am a large quantity generator.I certify that f have a program in place tcLreducethe volume and toxicity of waste generated to the degree I have determined <br /> O 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 /> V present and future threat to human health and the environment-,OR,it I am a small quantity generator,I have made a good faith effort to minimize my waste <br /> generation and select the best waste management method that Is available to me and that I can afford. <br /> ZSignet IS Month Day Year <br /> w Printed/Typed Name <br /> w O 1 ZJ <br /> T 17. Transporter t Acknowledgement of Receipt'of aterials ' <br /> R Month Day Year <br /> = <br /> Q A Printed lTyped Name ignsture - y <br /> t <br /> i. a <br /> P <br /> w O 1 . Transporter 2 Acknowledgement of Receipt of Materials <br /> i <br /> U T <br /> Printed/Typed Name Signature Month Day Year <br /> Z <br /> E <br /> i 19. Discrepancy Indication Space <br /> l F <br /> A <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 /> TSignature Month Day Year <br /> E y PrintedlTyped Name <br /> DHS 8022 A 0188) Do'Not Write Below This Line <br /> EPA 8700-22 Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9.85)Previous editions are obsolete. <br /> To: P.O. Box 400, Socromento, CA 95812-0400 <br /> - � taterrrr <br />