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w CalManla—Health and Welfare Agency DeparhneM of Health Servic <br /> .nA 'avedOMBNo.2050-0039(Expires9-3&91) See Instructions on bo of page 6. Toxic substances ControlProgrc <br /> ?lease pint or type. .1'am designed for use on elite(12 wrimr). Sacramento.Callfar, <br /> UNIFORM HAZARDOUS LGe"torsWEPAIDNo. Mc rtetDoa : :No. 2.Page sotrequirmation intbyFecerdam. <br /> w, <br /> WASTE MANIFEST 1 51 8 7 '1 31 'I °r ` <br /> ¢not equ red by Federal knv <br /> $�e rr�attof Noma_��nr,yd Mailing Address A 5'ate MaMest(kxurnent fan tro :'•4 9) <br /> ` UN eA"f KfAR0Kn-''INC Site:437 E. H.V1r <J <br /> t Pc'..�OT. Box i 5(155 Stockton B 4�q,a�r»tcnor:ID <br /> ' '�LUBn8A7f�sNdrn Ca' j4583 t' <br /> r <br /> n o�--%Y• / I I� I I I 1 I � I <br /> t 6.US EPA ID Number G Stc�e Trarsponer s:ID <br /> 5.Trarcponer 1 Comparry Name _ _• <br /> DILLARD TRUCKISG, IP:C, C to ID 9 1 6 19 12 IES 1'i D iRxvponerp Ptrnro <br /> 7.Trarpder2Compony Name S.US EPA ID Number E Stale 4oreportorilD <br /> I I I I I I I I I I I F innsoorter's icor» <br /> 10.lis EPA ID Number G State Fgaalrys,.� <br /> LgjDf"t4d FESIfty Narpglpq,¢.Spe nddresg,_r ices 1 I 1 i I l <br /> 2:00 Lokern Road <br /> vNi Buttonwillow, California 9320U C A D 9 8 0 6 i 5 2 J 5 H F°""y sPtnna <br /> 1 1 1 1 1 1 1 1 1 1 1 <br /> 12.Containers 13.total Id UM ; <br /> 11.115 DOT Owcription(lacksdkrg Roper shipping Name.Hurd Corm.and ID Number) No. I Type Quantity Wl7V0I ij Waste N=lor <br /> Stale-- <br /> J Q v . <br /> J <br /> Soil with Waste OilPA r <br /> MU G Non:- RCRA Hazardous Waste Solid J O D T ) 0 0 - T <br /> t» <br /> E I I I i I 1 - I <br /> �Z N b, StateO E <br /> N� R <br /> OE A <br /> T store <br /> z ' <br /> r"3€ O EPA/Otr <br /> �3 R <br /> d Stale <br /> Nq I <br /> b ... . - :. 1oF erlals'Gbted Above K HandlmgOodes forWates Listed Above <br /> c. <br /> w 15.special Handng Iminalkxn and Additional lneormalion <br /> U Z <br /> H <br /> Z Acceptance #M-1182 G-4-1-78878 nx)J t <br /> S Station ff 187 Jobf1143/22 APR 0 8 ' <br /> PROPER PROTECTIVE CLOTHING Emergency Phone 510-634-6850 <br /> W _ <br /> J 16. GENERATORS CERIINCATION: 1 hereby declare that the contents of this comignrnent are fully and accurately deurbed above by proper ilippt6'�r"and bR cl rl�.� <br /> Z pocked.marked and labeled.and are in d respechin proprrcondebnfortromPod by hlghwaya tdingtooppGcable Memalbndand national govenanenl nlgyWliSrn <br /> OF K 1 am a page qu rifly generator.1 certey,that I have a program in place to reduce the vohme and toxk:ily,of waste generated to the degree I have determined to be <br /> Zecon0rhir•'aii,proctkabll,and that 1 have selected the practicable method of treatment.donage-or dbporal currently ovaibble to me which rrinky&e the present and future <br /> sa that to human hearth and the en4on meM:OR,r I am a small auantlfygenerator.I have mode a good falfh effort to rrrnimim my waste generation and select the best waste <br /> maragement method that k avasoble to me and that I can afford. <br /> J - <br /> laa <br /> Month <br /> Year <br /> Q P",d/Typed Nares sgratae . <br /> a <br /> T 17.Tromponer 1 Acknowledgement of Receipt of Matedok .% <br /> pR Printed/Typed Nana signature Month Day Year <br /> > A <br /> Z 5 Sr .�C`f •= f•-_S ) ...� ..`y'�.;r":� �I G. I .x I I I <br /> P l8.Trans ner 2 Ackrawle einem of Rece aMoreno" <br /> C O Month Day year <br /> � R PMted/rYPed Name Sgnature <br /> w T <br /> OR <br /> QF 19.Dbaepascir Ydlcation space <br /> U A <br /> z C <br /> � 20.Facility Ovmer or Operator Ce nRsation of receipt of hazardous male nab covered by mb moni est except m rated in 11 em 19. ,. <br /> T Printedylypeci Name - Sanctum Month Day Yea <br /> Y .. - <br /> 11 <br /> f DO NOT WRITE BELOW THIS LINE. <br /> r <br /> eDHSp (12A0 Green: HAULER rcTA!NS <br /> EPA 6700-22 : <br />