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Stie of Colifooia—Environmental Protection Agency
<br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of : 6. Department of Toxic Substances Control
<br /> Please print or type. Forrq•designed for use on elite.(12-pitch)ty, er. Sacramento,California
<br /> UNIFORM HAZARDOUS 1.'Generator's US EPA ID No. Manifest Document No. 2.:Page 1 Information in the shaded areas
<br /> is not required by Federal law.
<br /> WASTE MANIFEST ' 1 of
<br /> 3;_Generator's Name aqd-Mailing.Address:.. A. State Manifest Document Number
<br /> H.J. ��.J. Heim. Y , i _ 226:;v. .. : L .
<br /> h - Rd-Box 57; Stp4ton, CA 95201 B. State Generator's IDL
<br /> LO A. Generator's Phone( 209) 932-5752 3a (_",: l R U i ? "' %1
<br /> N 5. Transporter I Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.]
<br /> aD
<br /> p� I �. D."Transporter's Phone 5.3,0/662-2841
<br /> .. 0 t J:'� 7
<br /> o Delta Oilfield, Services e A D 9 t? 6 9 5 6 t7 5.,0,662-841
<br /> 7. Transporter 2 Company Name 8.US EPA ID Number E. State Transporter's ID[Reserved.]
<br /> o�
<br /> F. Transporter's Phone
<br /> (V 9. Designated Facility Name and Site Address 10.,US EPA ID Number` G. State Facility's ID
<br /> )z S&J Landfill. I CJAJ r,11 91812101412141715
<br /> lo 6426 Haag Road l' H FaaiuY' i
<br /> Vace vi 11 CA 956871 C1 Al 0191812-1012 71 707/4.51-327 c, 1 r
<br /> IQ 12. Containers I4. Unit
<br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number)
<br /> No. Type, 11 Quantity Wt/Vol Waste Number
<br /> Z" a. State
<br /> RQ ASREESIPM, 9, NA 2212, PaII {NA'ERCO71 ) 151
<br /> > E G EPA/Other
<br /> 1'?- dX
<br /> Sy
<br /> O N 6. .State
<br /> .0000 E
<br /> NR EPA/Other
<br /> v A
<br /> o T c. State
<br /> 00 0
<br /> R EPA/Other -
<br /> d, State
<br /> Z
<br /> W
<br /> V EPA/Other
<br /> LU
<br /> N J. Additional Descriptions for Materials Listed Above
<br /> Z' - K. Handling Codes for Wastes Listed Above
<br /> V) 1 .,�i. l.tte , 91 .a._tl__ t;e. {k<.xh'..i ,
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<br /> Z15. Special Handling Instructions and Additional Information
<br /> 0
<br /> F - 24 alcUR, aKERM- NC! 530/662-2841 Job #4503
<br /> z Delta; PO � 1675, ffioodlAnd, CA 95776; EPA REGI(kq IX; Sari Joaquin Valley A );
<br /> 4230 Kiernan Ave; f odesto, CA 95356; ASBIMTTOS. SC?'VAL REQULRDVISi 40 CFR 61 .y
<br /> 1,7 -r . - a .K) A TARELM) STIE.: 2800 S C"aliforT'aStockton, Q4
<br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate) described above by proper shipping name and are classified,packed,
<br /> U` marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> IF I am a large quantiy'generotor;-I certify that.)have a program in place to reduce the volume and toxicity of waste generated to the degree I"have determined to'be economically
<br /> V) practicable and that I have selected the practicable method of treatment,-storage,or disposal currently available to me which minimizes the present and future threat to human health
<br /> and the environment;OR,if 1 am a small quantity generator,I have made a'good faith effort to minimize my waste generation and select the best waste management method that is
<br /> O available to and that I can afford.
<br /> Printed/Typed Name" Signature flMonth Day Year
<br /> W 7 t 6!Jif aR:c l��lL it-T, F j r
<br /> 5 T 17'-Transporter orter 1 Acknowledgement of Receipt of Materials
<br /> LUR Printed/Typed ed Name ' j? '� Month Day Year
<br /> N. TyP Vp,#C72,.�ic d�&E jti r5' 3 Signature
<br /> LU p y^— L J /7 !' V t` Vt! 7_ _ ,�' -r.;i+._fir_____
<br /> U_ ' 18. Irans orter 2 Acknowledgement of Receipt of Materials
<br /> 0 R Printed/T ed Name
<br /> w, T YP Signature Month... Day. Year
<br /> � R ;
<br /> V 19. Discrepancy Indication Space,
<br /> Z F
<br /> _ A
<br /> C
<br /> L ,�+�
<br /> l 20. FacilityOv}ner or O Ater uertificatj n of recei t of hazardous materials covered 6s is a�ifest eke t oted in Ite 19. y `
<br /> T Printed/Typed ame Signa,,e
<br /> Y1,,O)Iny ay °
<br /> DO
<br /> NOT;W rTE BELOW 61 LIN
<br /> Yellow; t TSDF SENDS THIS COPY Td GENERATOR WITHIN"30 DAYS.
<br /> DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state,
<br /> EPA 8706-22 produce completed copy of this copy and send to DTSC within 30 days.)
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