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C-1 <br /> Stole of Approved <br /> No. <br /> protection Agency-3 �' <br /> Form Appro�sed QNB No.X050.0079(Fip'vn 930.90 See Instructions on bock' a e b. <br /> i pleas print w t7Pe, form designed/or use on erne(12,1not) pewnM. _.�p 9 Depanmme of Te.k S„bv+o�ces Cee <br /> Secrwncnto,Celile.Na <br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest DocvmeM No. 2. Page 1 Informatiors in the shaded areas <br /> WASTE MANIFEST is not required by Federal low, <br /> C_ Cl Al C1 010111of <br /> J. Gemrotor's Nome and Mailing Address <br /> WOODW'ARD - CLYDE FEDERAL SERVICE q <br /> ^ 10370 OLDPLACERVILLE RD. STE. 104 SACRAMENTO, CA <br /> �16 <br /> A. Gaseratara pharie't <br /> Itt e <br /> - ° 95827 <br /> d 3. Transporter 1 Company Name 6. US.EPA ID Number <br /> coco <br /> AMERICAN VALLEY JCIAILJOJO 0 1 2 1 1 5 4 <br /> 7. Transporter2 Company Name 8. US EPA ID Number <br /> Q <br /> `z <br /> Z 9. Deilgnuted Facility Name and Site Address 10. US EPA ID Number <br /> REFINERIES SERVICE ' <br /> O 13331 N HWY 33 $ rr• <br /> PATTERSON, CA 95363 <br /> CAD 083166728 � �e <br /> 11. US DOT Description ncludin Pro Shipping 12. Containers 13. Total IL Unit x"y�xa�s <br /> = *'NON <br /> (' 9 per ppnq Nome,Hoxard Class,end ID Number) No. T Ovontiy Wt/Vol <br /> F; NON RCRA HAZARDOUS WASTE LIQUID gfi� <br /> I�5 0 <br /> o e T T G `x _- <br /> trdteum Recycling 0orporatlon certifies that the dove m ntion d <br /> f ste(s), more specifically identified by reference to the waste manife t <br /> Lbtg * \ <br /> e provisions of 40CFR261.6 and 23.4 pursuant t0.,40CF 261.3( .) <br /> �Y � ) hazardous waste generated from the recycling efforts va§ p1cin <br /> PETROLEUM RECYC NG COP RATIO <br /> : <br /> � <br /> 0 <br /> ' r_k <br /> 0 13. Special Handling Indrvetions and Additional Information n -- <br /> c <br /> USE APPROPRIATE PROTECTIVE GEAR <br /> �Z DESIGNATED FACILITY EMERGENCY CONTACT (600) 874-4444 <br /> GENERTOR EMERGENCY CONTACT W(916) 368-0968 <br /> `/ J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment aro fully and accurcrely described above by proper shipping name and are dasslfied, <br /> ' = packed,marked,and labeled,and are in all reapews in proper condition for transport by highway according to applicable federal,stare and international laws. <br /> ��11 If 1 am a large quortiy generator, I certify the I have a program in place to reduce the valume and I.Acity of waste ge«rated to the degree I have determined so be <br /> economically practicable and that 1 hove selected the practicable method of treatment,storage,or disposal currently available towhich minimizes the present and f~e <br /> threat to human health and the envir...n1l;OR,R I am a small quantity generatoq I hove made a good faith effort to minimizmee ny waste generation and select the best <br /> waste management method that is amgoble to me,and that I can afford. <br /> O Printed/Typed Name Signature Mom` Day Year <br /> } (,.L 0 JR- 2 rj 2 <br /> T 17. Tnonspan.r 1 Acknowled eenent of Receipt of Materials - <br /> J ♦ d/Fyped Nome Si noN <br /> N g \ Mo Day/ ar <br /> w z LL 1 , <br /> S r <br /> C 18. Trans Her 2 A<knowkd ement of Receipt 0!Mot<riah <br /> i Printed/Typed Nome _ Signature Momh Day Year <br /> E <br /> e I <br /> its 19. Discrepancy Indication Space <br /> N <br /> F <br /> A / <br /> C <br /> 1 <br /> L <br /> 1 Cc;;20. Facil' Owner or O orator Certification of tt of h.zwcfc z moserials covered }hi anif as nosed in Mem 19. <br /> T e Typed me <br /> y e <br /> Sipriolure qoYea <br /> P� l ver riYf 9 r <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br /> EPA 8770 �I <br /> DISC 00— (7/92) 122 s (Generators who submit haxordovs waste for transport ovtof-stole, I <br />