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State of California--Health and Welfare Agency 6^ <br /> Form Approved OMB No.2050- 0039(Ex ares 9.30.9' See Instructions on Ba- t Page 6 Department of Health Services <br /> p 10 and Front of P / Toxic Substances Control Divisior <br /> Please print or type. Form designed/or use on elite(%a/ h typewriter). \ylr Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA 10 No. Maiweet 2, page 1 <br /> Document No. Information in the shaded areas <br /> WASTE MANIFEST of Is not required by Federal law. <br /> 3. Generator s Name and Melling Address A. flap*Manliest DocumNumber <br /> CENTER PLUMBING CO. 90 4 2 731 6 J <br /> 2001 N. MAIN MANTECA, CA. IL etaie Generators 10 <br /> 4. Generator's Phone ) _ <br /> 7681 <br /> 5. Transporter 1 Company Name e. US EPA 10 Number C. gtats ransparter's ID <br /> Refineries Service 's •• <br /> N <br /> LO 7. Transporter 2 Company Name a. US EPA ID Number E #tete Tronapertses ID <br /> o F. rr}syisrter's i}torte <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number q stage .flews 10 <br /> a Refineries Serivice 11, <br /> 13331 N. HWY. 33 <br /> Patterson, CA. 95161 IC I Al DI 0181 '41 11 61 A' 71 PI A 5110 AW)P—AA71 <br /> 12. Containers 13. Total 14. L <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> . a. / "a <br /> G <br /> E f"PAIGk <br /> N <br /> E b: g <br /> R >. <br /> A <br /> Co T EPA/Other. <br /> v O <br /> N <br /> 7 R C. State <br /> m A/Other <br /> ¢ <br /> w d. sta4e <br /> F <br /> Z <br /> U EPA/Mer <br /> oWl J. Additional Descriptions for Materials Listed Above _ K FNndlkN Codes forWest"Listed Above <br /> j b 11 <br /> CL <br /> cc <br /> Z L <br /> H 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> 24 HE. EMERGENCY CONTACT: # 1-800-874-4444 <br /> 24 HR. EMERGENCY RESPONSE: CHEM TEL INC. # 1-800-255-3924 <br /> –t m <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> a. national government regulations. <br /> ¢ If I am a targe quantity generator.I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I bave determined <br /> O to be economically practicable and that I have selected the practicable method of treatment,store".or diayosel currantly available to me which minimizes the <br /> } present and future threat to human health and the environment;OR,if I am a small quantity generator,1 have male a good faith effort to minimize my waste <br /> U generation and select the beat waste management method that Is available to me and that I caa afford_ <br /> ZSignature Month Day Year <br /> W Printed/Typed Name <br /> C7 <br /> W1"AP _ <br /> WT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> Month Day Year <br /> Q A Pri d Name Signe + <br /> N <br /> LL <br /> O _ <br /> 18. nsporter 2 Acknowled ement of Receipt of Met rials <br /> U pMonth Day Year <br /> VT Printed/Typed Name Signature <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> TMonth Day Year <br /> y Printed/Typed Name Signature <br /> DHS 8022 A Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.6-89)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />