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m , ii0Ht - "7 j38C1,9 RLI, 't <br />State of 9alifornia-4ealth ani a far Agency <br />. (A-01-91) 20&,984-0991~<a B /R NEWSOMF <br />Form Approved OMB No.;2050=003$ (tzpires <br />Please print or type. ",(Form designed for use on elite (12 -pit t typewriter). - _ 1_1 F` <br />ACCT.:AFE Oa6205- 9i <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />DHS 8022 A (1 / 88) ( ` _ <br />�'�j"�"� Do Not Write BelowThisLine <br />EPA 8700-22 <br />(Rev. 9.88) Previous 16 (tions re bsolete. <br />Yellow: TSDF SENLIS THIS COPY TO GENERATOR WITKN 3^ D-- -1 <br />UNIFORM HAZARDOUS <br />1. Generator s US EPA to No. <br />Manifest <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />CAC 0 Q 0 2 7 1 8 -+ <br />2oocumem No.2 <br />(1 J :! <br />of <br />is not re q uired by Federal law. <br />3. Generator's Name and Mailing Address GENERATING SITE <br />A. State Manifest DocumentNumber <br />SiiELT+ l7I Tr CO2KPANY. PC M-')`4848 ��!q:1,L STATION <br />8t05 d l! <br />7 <br />ANAHEIM "'A o2803,ryr•. "�" 'TRAC_. BLVD <br />B. State Generator's ID T?yX _il NCI, <br />>. 3 <br />4. Generator's Phone ( l ' -Q, 5 20;7 3 31 2� "TIW 'C 'O CA G"� -, .i l; <br />n <br />Hv jj {�,) <br />5. Transporter 1 Compa y Name +'_pP US EPA ID Number <br />C. Slate Transporter's ID <br />t.: <br />CROSBY & OVERTOPd EMI ICAD 19 18 12 15 12 14 14 18? <br />D. Transporter's Phone 415!6" j3-03" <br />7. Transporter 2 Company Name 8. US EPA 10 Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />CROSBY & OVEPTON, INC. <br />H. Facility's Phone <br />1620 W 16TH STREET <br />LONG BEACH, CA 90813 IC JA I D 10 12 18 14 10 19 0 11. 19 <br />u 413/432-5445 <br />12. Containers <br />13. Total <br />14. <br />I. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />1 <br />Quantity <br />Unit <br />Waste No. <br />No. <br />Type <br />Wt/VDI <br />a. <br />State 134 <br />G <br />Waste Fial(linable liquid. n.C'�. :. . Fi3) -male 1i.iliiilj: <br />EPA/Other <br />(`t"DO-911 <br />tt <br />RQc; <br />i <br />a <br />i.3 <br />DQ! I 1 <br />E <br />b. <br />State <br />R <br />A <br />T <br />EPA/Other <br />O <br />R <br />C. <br />State <br />EPA/Other <br />d, <br />Slate <br />EPA!Olher <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />WATER/GASOLINE/SEDIMENT MIXTURE <br />a. , r <br />(� t <br />b. <br />WATERIJ�_g GASOLINE ! % <br />C. <br />d. <br />SEDIMENT-_% <br />15. Special Handling Instructions and Additional Information,_, <br />? <br />AVOID CONTACT WITH EYES AND SKIP? <br />"FLAMMABLE" PLACAKDING <br />~4 <br />REFERENCE 1993 <br />1s. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />and areclassified, 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 I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity <br />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 <br />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, I have <br />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 - <br />Ig <br />ON3FHAi,F GE Month Day Year <br />SHELL OIL CO 1 <br />T <br />R <br />1. Transportepfl Ac owle gement ofR46e1M ol Materials f <br />A <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />N <br />> <br />1 <br />S <br />P <br />r <br />18' Transporter 2 Acknowledgement of Receipt of Materials <br />P 9 P <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />a Pf m ti' <br />- <br />19. Discrepancy Indication Space <br />T, ` rT'i <br />4. <br />A <br />C <br />I <br />MARL <br />1 <br />T <br />20. Facility Owner or Operator Certification of receipt of hazardous materials c vered bythjs manifgat except asf>al �m ;,_; .1 t_l II <br />y <br />Printed/Typed Name �t <br />• <br />Sign ure (: I / T r ;Whin h Day Year <br />Qiti� <br />� t. ..>�.it - I <br />DHS 8022 A (1 / 88) ( ` _ <br />�'�j"�"� Do Not Write BelowThisLine <br />EPA 8700-22 <br />(Rev. 9.88) Previous 16 (tions re bsolete. <br />Yellow: TSDF SENLIS THIS COPY TO GENERATOR WITKN 3^ D-- -1 <br />