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.e{�A�mio--Ener ory enFal Progcison Agency ^ <br /> Form Approved OMB No 1050-0039(Expires A3496) i t �° See Instructions on back of page t3 Department of Torn Substances Control <br /> Please print or type form designed for use on el-(12pf")"—der <br /> Sacrament* 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 MANIFEST161A L 3 ( �„ _ 101of <br /> 3 Generalor's Name and Mailing Address � ! � <br /> F3 <br /> in '4 Generators Phone co f} 1 <br /> ao <br /> 5 Transporter 1 Company Nome 6 US EPA ID Number <br /> ao E RICKSON INC C A 1) Ei ti 9 4 t � 3 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number <br /> a <br /> 7L) <br /> Q 9 Designated Facility Name and Site Address 10 US EPA ID Number <br /> A C9 FTC pASCIN, INC <br /> O 13331 N HWY 33 <br /> 7 a �1 iT r �Iy �}tJ ski! L A 11 $ � 1 � <br /> U 32 Containers 13 Total 14 Unita Z 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) NO Type Quantity Wt/Vol <br /> 3 a R0, HAZARDOUS WASW LICiLl FE),, N t i S yg r V <br /> C4 E( BDIZENE) , 9, 64A 3L,82, III fr;(i;t' I EW, #31 T 'T' {� G <br /> 0 <br /> CO N Petrbleum Recycling Corporation certlf'es that the above Mentioned <br /> co <br /> n R 4 '9Ste(sj, r'')orQ s;)eclilr'c3:(}� !u�'nVfleo by reference to itlo \%aste mar1de, <br /> v A „ lU <br /> T <br /> Oi pro;,lscln s Ct 40CFR261 G and23 4 pi ii-. }a'it It-, 41 DCR61 ,cti <br /> R .r? nazMrdo ; \'t, :e oener2tea from th r:cy;Ilrrc� effort auj <br /> ' I <br /> fM <br /> '� 1Ypled in G v s y, r i $fafy <br /> LU <br /> RECYC,_il\JG CO RATi N EPAl ^ <br /> J Addilianat 4escsipiscim for ftlatenols Above K Hondlmg Codes for Wastes listed Above <br /> Prof lie 089 <br /> a d <br /> J <br /> a <br /> Q 15 Special Handling Instructions and Additional Information <br /> i r l J � rl 1 i^i[ ' ..y t. `.- 4 rW t it=:F4 Z it-V <br /> w <br /> I1t10ZCfE'11CJ F�1 xlry ,`fir+-A =�' -!- <br /> A h <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 <br /> a packed marked,and labeled and are in all respects in proper condition for transport by highway according to applicable international and national govemment regulations <br /> U <br /> JIf I am a large quantify 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 <br /> a economically practicable and that t 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 enwromnent OR if I am a small quantity generator I have made a aith effort to minimize my waste generation and select the best <br /> ix I waste management method that is available to me and that I can afford r <br /> O PriritttdDay <br /> /ITypNaiPs� Sig 1 r r' �or <br /> ,, r <br /> Z 1 17 Transporter i Acknowledgement of Receipt of Materials j 3 <br /> W DaY *-V/ <br /> A ! <br /> A Pnillgd/Typed Nome , r Sigriot}rfe f� r 7 / J <br /> It <br /> w s E �l <br /> w0 18 Tramr 2 Acknowied anent of Recei t of MaterialsLa- 1 Printed/Typed Name Signature Month Day Year <br /> o 1 <br /> A <br /> V) 19 Discrepancy indication pace <br /> Z0 L <br /> I 20 Facd Owner or r r Certificationrecei of hazardou mate covered b this manifesliexce os rioted in <br /> 19 r <br /> YPrinted/Typed Name �/! J ignature % �' <br /> DO NOT RITE BELq THIS LINE <br /> Yellow TSDF SEND$THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> (Generators who submit hazardous waste for transport out of state <br /> DISC 8022A (1/95) produce completed copy of this copy and send to DTSC within 30 days) <br /> EPA 8700--22 <br />