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State QL&&WA?fav—Health antl Welfare Agency A p Toxic Substanceess• DepartmentHealth Services <br /> Four,Approved OMB No.2050--0039(Expires 9-36-9 Control Division <br /> Sacramento,California <br /> z Please print or type. (Form designed lar use on elifeOtch typewriter). <br /> 1. Generator's US EPA ID No. tDocwnfi <br /> 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS WASTE MANIFEST ; L r" _ � aGf a not required by Federal law. <br /> 3. Generator's Name and Mailing Address I State Manifest DocumentNumber <br /> kt;q „-, _5 I4.r .o(i 898016 36�I'dnJ State Generator's l0 <br /> 4. �Al IZO 96eh ( , `-fi I rcn77 f,Jr , 1 <br /> 5. Transporter 1 Company Name e. US EPA ID Number C. State Transporter's ID <br /> n D. Transporter's Phone <br /> N <br /> m8.Transporter 2 Company Name e. US EPA ID Number E. State Transporter's ID <br /> b F. Transporter's Phone <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number O. Stets Facility's ID <br /> Refineries Service <br /> v 13331 N. HWY. 33 H. Facility's Phone <br /> a Pa ter'son CA. 95363 5 3 1 6 5 1 7. 8 800-874-4444 <br /> Z 12. Containers 13. Total 14, I. <br /> U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Wast,No. <br /> w No. Type Wt Vol <br /> Q State <br /> _ O EPATOIher <br /> H 1084 H( t,� '+ 0 0 1 i' 'i' U /3 O G EXEMPT <br /> State <br /> E b. <br /> R <br /> A EPA/Other <br /> T <br /> O <br /> R c, rEP-41-01h.r <br /> State <br /> c <br /> ¢ d State_ , <br /> w <br /> H <br /> Z <br /> W EPA/Other <br /> U <br /> Z J. Additional Descriptions for Materials Listed Above : Handling Codes for Waebtse Llalad Above <br /> O.TL S WATER N/A e70 151/ . <br /> 2 C. d. <br /> J <br /> 4 <br /> U 16. Special Handling Instructions and Additional Information <br /> Z WEAR GLOVES, GOGGLES & PROTECTIVE CLOTHING <br /> IN CASE OF SPILL CALL EMERGENCY RESPONES -- <br /> 800-874-4444 OR (209) 892--6742 <br /> J <br /> U <br /> 18. <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that lin contents of this consignment are fully and accurately y described above pl proper teemang name <br /> � <br /> and are claesitied,pecked,marked.and labeled,and are in all respects In proper condition for transport by highway according to applicable intemetlonel and <br /> d national government regulations. <br /> 7 <br /> ¢ It I em a large quantity generator.I chat I that l have a program ti place to reduce the volume and toxicity of weals generated it the degree I have determinedminimizes <br /> th <br /> U to be economically practicable and <br /> that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> Y present and future threat to human health and the environment;OR,if I em a small quantity generator.I have made a good faith effort to minimize my waste <br /> U generation and select the beet waste management method that Is available to me and that I can afford. <br /> Z ;'I <br /> L0 Printed/Typed Name SI natureMonth Day Year <br /> \ 1 I <br /> u¢1 M 1 .l,t- pl, !�L,V, �...;..y� Q • r <br /> Ul <br /> W T 17, Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name Bigatuti Month Dey year <br /> O P <br /> w O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> G T Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> �4ua) G, I � Co � <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest ex rpt as not 71in Item 19. <br /> T - Signa r Month De Year <br /> y Printetl/Typed Name <br /> DHS 8022 A(1/88) DO Not Write Belo Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 YAYS <br />