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State of California --Health and Welfare Agency <br />Form Apj oved OMS No. 2050-0039 (Expires 9-30.91) <br />�fg%236 ¢Tint qr type: Form designed for use on elite (I typewriter). <br />See Instructions Back f Page 6 Department of Health Services <br />end Front of PI Toxic Substances Control Division <br />Sacramento, California <br />j <br />UNIFORM HAZA (�S I. nerator's US EPA ID No. Manifest <br />e. Pa ga 1 Information in the shaded areas <br />i <br />Document No. <br />WASTE MANIFESTj ^I <br />of is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State k4saffest Dowsment Number <br />PRECISSI FLYING SERVICE <br />a. l5we atom's ID <br />4. 1i a nod&QWer) Sacramento Road Lodi, CA. 95242 <br />1111no <br />AQ :44Q <br />5. Transporter 1 Comps y ame 6. US EPA ID Number <br />C. Tran er's to Lj <br />Refineries Service IClAlDl0i8i3ijl6j6izj <br />D. Tranapot4sre ne <br />7.., Transporter 2 -Company -Name --- - 8. US EPA ID Number <br />E. Stele Tranaporteea 83 <br />F. ramaptt a <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State FWIW9 to <br />Refineries Serivice <br />I I I_L.LL L I <br />H. Facility's Phone <br />13331 N. HWY. 33 <br />Patterson. <br />12. Containers <br />13. Total <br />14. <br />L `, <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />ata No. <br />No. Type <br />Wt Vol <br />a. <br />Bate <br />G <br />EPA/ <br />*0�7�,)ia <br />s n: <br />E <br />E <br />b. <br />I <br />State <br />A <br />T <br />Cd fi�TA1-EA1_1h <br />ESA/ <br />R7 <br />o. i <br />State 77 <br />EPA/ <br />d. <br />stow" <br />A! <br />x <br />J. AdditTonal Descriptions for Materials Listed Above <br />K. HanAng Codes for Wastes Listed' <br />x <br />a <br />d. <br />15. Special Handling Instructions and Additional Information <br />4 HE. EMERGENCY CONTACT: # 1-800-874--4444 <br />24 HR. EMERGENCY RESPONSE: CHEM TEL INC. # 1-800-255-3924 <br />,6. <br />GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and <br />national government regulations. <br />If 1 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 <br />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is available to me and that I can afford. <br />Printed/Typed Name Day Year <br />[Signaturl—/),,Month <br />f <br />T <br />R <br />17. ren orfs i_Aikn3wIedgVnFent of Receipt of Materials <br />A <br />Prin Typed Name Signa Month Day Year <br />N <br />4C. <br />S <br />LA f <br />P <br />O <br />na18. reporter 2 Acknowledgement of Receipt o aterials <br />T <br />f R <br />Printed/ Typed Name VI <br />Signature Month pay Year <br />1 E <br />19. Discrepancy Indication Space <br />F <br />A <br />I <br />L <br />1 <br />T <br />_ <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />y <br />Printed!Typed Name <br />Signature,. Month Day Year <br />• a <br />b <br />DHS 8022 A <br />EPA 8700-22 <br />(Rev. 6.89) Previous editions are obsolete. <br />Do Not Write Be ow This Line <br />Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />2' <br />To: P.O. Box 400, Socremonto, CA 95812 <br />