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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9.30-991 See Instructions on back of pa At. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite f l2-pitchy ricer. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST O aft <br /> J. Generator's Name and;11ailin Add rEss ���� � A. State Manifest Document Number119V14245482011 <br /> O GG`iy� � y 6 State Generator's ID <br /> n4. Generator's Phone( O ) 3d <br /> N 5. Transporter 1 Compan ame 6. US EPA ID Number C. StateTransporter's ID[Reserved.) <br /> h <br /> o CLEARWATER ENVIRONMENTAL C A R 0 ,0 0!0 0 7 0 1 3 D. Transporter's Phone (510)476-1740- <br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Tronsporter's ID[Reserved.) <br /> OQF. Transporters Phone <br /> 00U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> �Q ALVISO INDEPENDENT OIL- 611411121 ell <br /> LO= 5002 ARCHER STREET H. Facility's Phone <br /> �0 ' ALVISO CA 95002 CAL 0 0 0 1 i 6 1 7 4 3 (510)476.1740 <br /> Na 11. US DOT Description ncludin Proper Shipping Name,Hazard Class,and ID Number •12. Containers 13, Total 14. Unit <br /> U p (' g p PP g ) No. Type Quartiry Wt/Vol I. Waste Number <br /> Z a. State <br /> t: OUS <br /> 3 G -WA9NE> -p.. tf er <br /> E / <br /> o N <br /> o E <br /> N R O EPA/Other <br /> A <br /> T c Stare <br /> o <br /> co O <br /> R i I EPA/Other <br /> w d. State <br /> Z : <br /> su <br /> U EPA/Other <br /> LU <br /> N J. Additional Descriptions for Materials Listed Above K. Handl;ng Codes for Wastes Listed Above <br /> 0 11A , C`� V `UC�\ b. a/ t/ <br /> W <br /> v <br /> C. d. <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> WEAR PPE 24 HOUR EMERGENCY KIRK HAYWARD 510.476.1740 ERG#171 <br /> a , <br /> Z <br /> -/3 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international ono national government regulations. <br /> U <br /> If I am a large quantify generator,I certify that I have a program in place to reduce the flume and toxicity of waste generated to the degree I have determined to be economicoll�r <br /> °- practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healtts <br /> V) and the environment;OR,if I am o small quantity generator,I have made a good faith effort to minimize my wase generation and select the best waste management method that is <br /> IX avoilable to me and that I can afford. <br /> O <br /> } Prinrsd/T S' u Month Day Year <br /> Z aeo p 3 <br /> tL T 17. Trans orrer 1 Acknowledgement of Receipt of Materials <br /> o0c R <br /> w A Printed/ d Name $i re Month Day Year <br /> X O <br /> WP 9��& Z&V,/Z <br /> S <br /> U. a18. Tran Ma <br /> orter 2 Acknowled ement of Recei t of terials <br /> 0 A Printed/Typed Name Signature Month Day Year <br /> N E <br /> Q' R <br /> U 19. Discrepancy Indicotion Space <br /> IF <br /> A <br /> CI <br /> I , <br /> I ' 20. Facile Owner or O erotor Certificate receipt of hazardous materials covered this manifest exce s nate n Ite 19. <br /> T Pr' ted/Ty d Name K.tureMo <br /> nt Day Year <br /> Y —1 <br /> V DO NOT WRITE BELOW TIOS LINE. <br /> DTSC 8022A(1/991 White: /SENDS THS COPY TO DT5C WITHIN 30 DAYS. <br /> EPA 8700-22 To: P.O. Box 300C, Sacramento, CA 9„812 <br />