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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9.30-99) See Instructions on backage b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(I 2-pitcwriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> /) (1010.21 [y �j C� is not required by Federal law. <br /> WASTE MANIFEST <br /> P7 / J On j <br /> 3. Generator's Name and Mailing Address A State Manifest Document Number <br /> 1+98834 , <br /> p B State Generator's ll)qv <br /> 7a 7►Ny� - <br /> LO 4. Generator's Phone <br /> n <br /> N 5. Transporter 1 Company Name �ft& US EPA ID umber G State Transporter's ID11, <br /> LO <br /> VALLEYQ M15V26o.i i.A♦.o P-t!M serti c•7-!^` a rs "y y '0Transporters Acini <br /> 1rdr1L L nV -' <br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E State 3'ronsporter's 1D <br /> F Transporters Phone , <br /> . ,z <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G State FaCilt s ID <br /> a I' NUS" RIAL,S.L.IiVIC L OIL C(), INC ra Via; `: r � � V� <br /> 3 7(? t!a_ 3�S ?:T H Facdify's,Phone' r <br /> )p <br /> . <br /> r, / I :9O'k1aC., V ; ryry ✓ q <br /> S : 7 b <br /> .t <br /> }V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> 12. Containers 13. Total 14. Unit <br /> No. Type Quantity Wt/vol 1. Waste Number.' <br /> Z a. State.ez <br /> -� t-JON-RC IRA HA7A>^f)0[J'S th ASTE` [._1C, 0D <br /> j Ci (Q11.?r WATEP '? T C EPA/Other ' <br /> o N b. trate - <br /> c°oo E <br /> N R EPA/Other <br /> v A <br /> o T ` score <br /> ado O <br /> R EPA/Other <br /> ad <br /> Lu d. State <br /> ZLu <br /> her <br /> J. <br /> f <br /> 1. Additional Descriptions far Materials Listed Above K. Handling Codes for Wastes Fisted Above <br /> a. 0,1 . <br /> a <br /> OILY V - <br /> N <br /> Lu <br /> (pvr�t� gro�7nc�l.iGc'C�'� <br /> c. d. <br /> Q <br /> 0 15. Special Handling Instructions and Additional Information <br /> Z GoLC)V <br /> w F-MFRGE"N+yY I`+10N 209-667-8857 <br /> 857 <br /> H <br /> 16. GENERATOR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a 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 /> h and the environment;OR,if I 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 /> available to me and that I can afford. <br /> O <br /> UPrinted/Typed Name I ( ® Signature r Month Day _Ye <br /> Z �4"R,ta CSS , e.�►" r� _��t�___� (ar <br /> Z5R 17. Transporter 1 Acknowled a nt of Receipt o Materials <br /> w p Printed/Typed Signature Month Day e j <br /> N <br /> LU �� Pr <br /> LL 0 18. Trans orter 2 Acknowled lment of Receipt of Materials <br /> TPrinted/Typed Name ,._.... .Signature Month Day Year <br /> Lu E <br /> cn R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous lmoteriols covere his m i est xce t as noted in Item 19. <br /> . T Printed/Typed ame Signal e Month Day Year <br /> loll I I 1,i�ll <br /> DO NOT WRITErELOWLINE. <br /> TDF SENDS THIS COPY T(J�GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (4/97) ( enerotors who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />