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<br /> �...••t3fate of California-Health end Welfare � •-•� - Department of HaakA Services' ,
<br /> l:Form.Apprv+ied OMB No.2050--0039(Expires 9.30-118) Toxic Substances Control Division
<br /> L Please' rant or tvD9. ' Form designed for use on elite IbMw1h t @writer. Sacramento,California
<br /> :~'UNIFORM HAZARDOUS t Generators US EPA ID No., ' Manifest 2. Paps 1 Information in the shaded areas
<br /> Dlie t is not required by Federal law,
<br /> " 'WASTE MANIFEST C A D 9 8 1 4 S 9 9 4 0 om
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<br /> 3 Generator's Name and Mailing Address� A tat d at Do u+mr'e��n umber p
<br /> ?'-"� `fr !t- �. -41•..; li�:'�X%aVr`+LWA7. CO..,. I,!e•.,�p P'' .V
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<br /> „t r �... "'1�IEyl1MOND & E -WORTHr A
<br /> � CA:-•95203,"; f...V+..w w..er.r.�•. ..-.:;,y.w. 4'0. ► •.ri-+ ryr,wBteta GenefetQr:e.lD
<br /> 4:Generafora one ) �•►:♦ i r • tie r '' +. ' 3 tl�fr
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<br /> Cr 5r;Transporter 1 Company Name , 6. - .. .'LS EPA ID Number. :•'fir•C. State Tranaporter's ID.
<br /> gLo '' , • y~„- Transporter's Phone
<br /> Y ,t Transporter I C mpany Name 4 8. US EPA ID Number E. firsts Transporter ID
<br /> r.. F+Tranaporter'a Rho
<br /> 8 Designated Facility Name and Site Address l0. US EPA ID Number GState F,ecilit s D
<br /> -GIB SON OIL--& REFINING CO INC Z:,' ” • .
<br /> CO2�RICAL_DRIP I H..Eacility's Phone ti
<br /> =" BAKERSFIELD CA . 93308 r••'" '�
<br /> , C A-,.D 9 8.0•:8. 6 .,3 1' .;. 803)327--0k 13 `
<br /> ^•>, 12. Containers 13, Total 14. 1 iti
<br /> O 11 US DOT.Deacriptign(including Proper Shipping Name,kelard Class,and,ID Number) Ouentity Unit YY,aste No
<br /> LL. No. I Type Wt Vol
<br /> v t+ r a ; TASTEOIL SOLUTION, stae�,,
<br /> E". CCIcOUgTIBLE +LIQUID, NA> �70 , x ,ani s " 4+l r FPA/ ..�.
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<br /> m A EPA)Other
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<br /> ZJ. !►ddiAtioTn�a'Deztcriptiona for Materials Listed Above , + X. handl+nq Dode1}for Weetes Listed Above fjF
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<br /> O 15. Special Handling Instructions and Additional Information f
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<br /> Z CLOVES SAFETY GLASSES - ;
<br /> L) GENERATOR'S CERTIFICATION: I hereby'declar that the contents of this consignment arefull and accur tely described above b -�
<br /> Q g Y Q Y Proper shipping.
<br /> name and are classified, packed,_marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable
<br /> International and national government regulations. `
<br /> If i am a large quantity generator,1 certify that I have a prog(am in place to reduce the volume and toxicity of waste generated to the degree I have ;
<br /> �_ :>�delermined.to.be.P nomically fr�cticable and 4h#t I have selected-the,practicpbIs-melgod-of 4treltment,storage; or disposal rryntly evailatim to
<br /> p me which minimize¢ th present,and future,thre4t to human health and.tRe environTent:OR,cif I am A..timall quantity generator, Irhave'made a good
<br /> :.� faith effort to minimize my waste generation and select'the nest waste rtianagemeAt fnethod that is available to fie and that I can afford.
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<br /> Print /T ed Nam
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<br /> YP y"� Signatµr �. Month OeY Year
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<br /> r> w R 17• Transporter 1 Acknowledgement of Receipt of Materials
<br /> A Prrtyped
<br /> Z N Name a urs Mgnth Day year
<br /> O O 18. Transporter 2.Acknowledgement of Receipt of Materials
<br /> L 7 Printed/Typed Name ` Signature Month Da Year
<br /> Pis /p dication ace
<br /> A
<br /> }t j Ly. '„_./f -i. i .J`�-. .. '. .y 4r � .�; 'L t jt �1 ++ •.. ..•. > + t. ,'..+ :y n'�iJ f ..
<br /> r (•-: 20. Facility Owner or Operator Certification of recelpt.ol hazardous materials covered-by this manifest except as noted In Nem 19.
<br /> " z Y r Printed/Typed Name
<br /> ISignature. Month -Day YrYear
<br /> DHA 8700 A /67)
<br /> EPA 6700-222 Yellow:"•TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS INSTRUCTIONS ON THE BACK r
<br /> (Rev.9-86) Previous editions are obsolete.
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