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State of California---Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Contra; <br /> Please print or type Form designed for use on etre(12 pitch)typewriter Socromenfo California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Information;n the shaded areas <br /> ri is not required by Federal law <br /> WASTE MANIFEST i 71 �� rr 7 J" of <br /> 3 Generator s Nome end Mailing Address C Pf S l )` �r r��U r` �o n A 'State Mon;fesl Documenl Number 211-4 <br /> 114� 7"? <br /> 0 <br /> Ill( �. 'mss+ <br /> 8 State Generator s ID <br /> 1LO 4 Generators Phone Y <br /> N 5 Transporter I Company Name 6 US EPA ID Number r C State Transporter s ID[Reserved I <br /> 4 LO �^� n p 7 p p <br /> r F�VIERICAIN VALL EY 'J'>ASTIr OIL. sY 1 8 f 8 D Transporter s Phone lv^iii <br /> 4 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E Slate Transporter s ID[Reserved[ <br /> J <br /> J F Transporter s Phone <br /> Flac�y[i(�IU and Sale Address 10 US EPA Ip Number G SlaleFa�}tty ID t n 1 � � <br /> ' K / r.. Fi -y Oi <br /> d � - <br /> z You ALMOND DR <br />� o . It_VERSF3RINt;S NV 8(,:+429 702_5 r„ <br /> J <br />�Q 11 US DOT Description(including Proper 5hippmg Nome Hozard Closs and ID Numbed 12 Containers 13 Total [4 Un;t <br /> pv t� No Type Ouantiiy WI/Vol I Was a Number <br /> Z a NC,14-RIC A s'I+p�ef1!'d�cRDi1Lli�l),.�7:��1�rli;VAST Ls LIC�L.,;I� State �: I <br /> 7 t7 t <br /> OILY I.AiA f ER � � V 1 T T EPA/Other <br /> E 6 Slate <br /> C) <br /> O Id <br /> co E <br /> 1",1 R EPA/Other <br /> CN A a <br /> o T Slate <br /> co <br /> (Z EPA/Other <br />'Z d <br /> Z State <br /> w <br /> V EPA/Other <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> OILY 'i fI�I Ire �C5f-F C tore a 09 b <br /> U-1 r <br /> cle <br />'Q <br /> Z 15 Special Handling Instructions and Additional Information <br /> 0 <br /> Q GL 0 V iF B <br /> 12: EMERGCNCY PhOt�,jE 269-66 it-83157ILLJ <br /> i— <br /> .J� 16 GENERATOR S CERTIFICATION I hereby declare ihat the contents of this consignment are fully and accurate)y descnbed above by proper shipping name and are[IpssrLed packed <br /> marked and lo6eled and are in all respecls in proper condition Far Transport by heghway aecordmg to applicable international and national government regulations <br /> J I <br /> J If E am a large quantity generator I certify that I have a program ;n place to reduce the volume and toxicity of waste generated to the degree I have delerm;ned to he economically <br /> rn <br /> practicable and that I have selected the racticable method of treatment storage or disposal currently available to me which minimizes the present and future Ihreot to human health <br /> and the environment OR ;f I om a small quantity generator I have mode a good faith effort to minimize my waste generation and select the best waste management method that is <br /> cii avarla6le to me and that I can afford <br /> }. Printed/Typed Name "'t - Signalur �rL /� �r J Month Day Year10 <br /> J <br /> Z IffJ 'J f�vC_ GY if ,— �f/G(rr fi2..�"+ rrJ 1 <br /> w T <br /> U+ R 17 Transporter 1 Acknoydeclgement of Receipt of Materials <br /> w A Pr;nied/Type a S;gnolure 1 �' Month Day Yeor <br /> ;i 0 18 Trans orTe`r�2 Acknowlcc ement o{Recei t of Moierrals �-� <br /> C) R Printed/Typed Nome <br /> Lo <br /> w Signature Month Day Year <br /> E <br /> Q R T <br /> U 1 1 9 Discrepancy Indication Space <br /> � F <br /> A <br /> C <br /> I <br /> L <br /> 20 Facility lar Owner or O eraCertification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> T Printed/Typed Name Signature Month Day Yeor <br /> r, k <br /> DO NOT WRITE BEL'bW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />' DTSC 8022A (1/991 (Generators who submit hazardous waste for 'ansport oui of stole <br /> EPA 8700-22 <br /> p;ocluce completed copy of Iris copy and and to DTSC within 30 days I <br />