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• -R .,ental Protection Agency <br /> ...2030-0039(Expires 9-30-94) See Instructions on back of )`;3 6. Department of Toxic Substances Control <br /> Form designed for use on elite(12pitch)type. ,ter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document t o. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST IC JA01010101413131 41 1 .11MM 10 Oil 1 of 1 <br /> 3. Generators Name and Mailing Address QUIK STOP MARKETS A. State Manifest Document Number <br /> 'r' (510) ' 657-8500 A`LTN: NIR. JACK GRIFFITH 92466073 <br /> P.O. BOX 5745 8. Stets Gwrators ID <br /> sty 4. Generators Phone ( ) FRE14ONT F CA 94537 <br /> 00 <br /> S. Transporter 1 Company Name 6. U$EPA ID Number CState Transporters ID <br /> °D FALCON ENERGY C F 91 8121512161 8 51 D. TransporrorsPharw (7120-9) 463-7108 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporters ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's 10 <br /> GIBSON ENVIRONMENTAL 7 <br /> ,(Q END OF COMMERCIAL DRIVE H. r«ailys Pheme <br /> ^tea SAKERSFIELDF CA 93308 D y 8 8 8 1 7 ( 805) .323 21?$ '-, <br /> ♦v f <br /> 11. U$DOT Description(mbding Proper Shipping Name,Hazard Class,and ID Number) 12. Containers . 13. Total 14. UnitNo. Type Qua Wt/Vol I. Waste Number, <br /> NON RCRA HAZARDOUS VIASTEF LIQUID state 223 <br /> c E 0 t o I TIT G NE <br /> do b <br /> N . State <br /> c4 R EPA/00w <br /> ro T -" State <br /> p <br /> LU <br /> It EPA/Other _ <br /> W <br /> Z d. state <br /> Z <br /> W <br /> 1J EPA/C»her <br /> W <br /> h <br /> Z W A 0 dextipfiosss for Materials Listed Above K. Handling Code for Wastes listed Above <br /> (W49TE FUEL/G'A.Cj'R b. <br /> Uj <br /> C. <br /> C ♦ r _ <br /> 0 15. Special Handling Instructions and Additional Information 24 hOUR EMERGENCY RESPONSE NUMBER 1 ( 800) 399—HELP <br /> Z 11a. #14761 -J`TATjc�7�13 Z <br /> W <br /> x <br /> r <br /> 16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of the consignment aro fully and accurately described above by proper shipping name and aro classified, <br /> < ked,marked,and labeled,and are in all res in proper condition for transport b highway according ro applicable federal,:taro and international laws. <br /> Q Pac pacts P pe Po Y 9 Y n9 PP <br /> V <br /> If 1 am a large quantity generator, 1 certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> ydj threat to human health and the environment,OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that Icon afford. <br /> 0 Pn /Tfped Name Si a Month Day Year <br /> U i i t <br /> Z T 17. Traosporter 1 Acknowled ement of Receipt of Materials <br /> LU h P' d/ ped Name Signature (^7 Month Day Year <br /> w s ass �A ���b % <br /> P <br /> 0 18. Trams r 2 Acknowledgement of Receipt of Materials <br /> W ■ <br /> LL T Printed/Typed Name Signature Month Day Year <br /> 0 R <br /> N19. Discrepancy Indication Space <br /> Q F <br /> fJ A <br /> Z C <br /> I / <br /> L <br /> I 20. Facil' er or rotorrhfic on of receipt of hazardous materials covered b is manifest except as noted in Item 19. <br /> T Prints type Nanta Signature � Month Day Year <br /> y I" <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />