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<br />'State ptCalitomla—Health and Welfare Agency Department of Health Services
<br />Forth App roved .OMB No. 2060-0039 (Expires 9130.9,. Toxic Substances Control. Division
<br />.` Please t4tint or .pe- (Form designed for use on 00 tch typewriter). Sacramento, California
<br />UNIFORM HAZARDOUS ` erator'a US EPA ID
<br />OH8 8022 A (1 /88)
<br />EPA 8700--22
<br />(Rev. 9.88) Previous editions are obsolete.
<br />Do Not Write Below This Line
<br />Blue; GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS
<br />To: P.O. Box 400, Sacramento, CA 95812.0400
<br />No. Manifest u�
<br />n
<br />Pepe t
<br />Information in the shaded areae
<br />WASTE MANIFEST
<br />1
<br />jCjAjTj0j8j0j0j2j!I1I8_j4tf°
<br />of
<br />is not required by Federal law.
<br />3. Generator's Name and Mailing Address
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<br />tl 8 ou a b t� ;
<br />P ific Boll/Environizental xa=gement
<br />r
<br />2600 Cemluo Rammil, Room 23050, Swgwwas Q, 94583
<br />4. Generator's Phone (409) 491-4335
<br />.. �.
<br />6. Transporter 1 Company Name 8. US EPA Id Number
<br />°
<br />American Environmental C A A 0 0 9 4 6 6 3 9 2"k,
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<br />111111111111
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<br />Z.Transporter 2 Company Name � "�8. rjUS EPA 10 Number
<br />7.
<br />E„ ffita�A� a�or#+r� .�, , ,�,„• � , �., ,
<br />F Trans a s�h�te�` �” r
<br />g. Designated Facility Name and Site Address 10. US EPA ID Number
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<br />G 8tat1 al tet
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<br />E s.
<br />8r f oksQn xporated r
<br />255 Parr So evard
<br />Ri�tl�nd, ., 94801 �C A A 0 0 9 4 6 6 3 9 2
<br />.
<br />I. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number)
<br />12. Containers
<br />13. Total
<br />Quantity
<br />14
<br />Unitat
<br />ftpc�'
<br />No.
<br />Type
<br />Wt/Vol
<br />®' Waste Empty Storage Tank, Non-�RCRA Hazardous;
<br />G
<br />Waste Solid
<br />0 1
<br />T P
<br />D 2 0 0 0
<br />Pa/c>1
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<br />16 Special Handling Instructions and Additlo I I formation
<br />n�l>ting . t, t . W t Street, i,
<br />(415) 823-7777
<br />ERG 927
<br />18.
<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 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 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
<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 />4 <', present and future threat to human heattq and the environment; OR, if I am a jUnall quantity generator, I have maAe a good faith effort to minimize my waste
<br />generation and select the beat waste ma gement method that Is availabletr a and that I caord.
<br />P /T ped Nam n e
<br />1Nontb, pay Yea'..
<br />17, Transporter 1 Acknowledgement c4 Receipt of Materials
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<br />A
<br />Pri /Typed a/m�tl�( r
<br />Si urs
<br />Month Day ear
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<br />I'/"'I* /�� / u
<br />y l
<br />O
<br />18. Transporter 2 Acknowledgement of Receipt of Materials e
<br />TPrinted/TYPeQ
<br />Name "
<br />Signature
<br />(Month pay Year
<br />19:. Discrepancy Indication Space
<br />A
<br />C.
<br />1
<br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br />T
<br />Y�
<br />Printed/T a Name
<br />rP.Q.
<br />Signature
<br />Mone Day Year
<br />h
<br />OH8 8022 A (1 /88)
<br />EPA 8700--22
<br />(Rev. 9.88) Previous editions are obsolete.
<br />Do Not Write Below This Line
<br />Blue; GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS
<br />To: P.O. Box 400, Sacramento, CA 95812.0400
<br />
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