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40041 aith and Welfare Agency See Instructions on Back of Page 6 Department of Health Services <br />No. 9 (Expires 9-30.91) <br />and Front o *7 Toxic Substances Division <br />,or typo. Farmdesigned for use on qM2,pitch typewriter). Sacra a <br />UNIFORM H ADOU$ Qenarator s U8 EPA iD Manifsot 2. Paget Information in the she are" <br />AST MANIFEST C ( 1T a t No. <br />1 g of 1 is not required by Federal low., <br />3. (tertarator's Name and Mailing Address,t <br />�I.�i� yv S G/I} `i7 b Q �'�/rt Y A. 8tsee � Dactuttant Nwnber <br />X57(/ '. J�'F '�t,ol-�c rl�f • ! $� E!lr�i ®� /r '�fS` / <br />C Its Sate ton's ID <br />'Ce!� <br />4.Generator's Phone <br />b. Transporter 1 Cornpiiny Name 8. US EPA ID Number C- stoo Trsrtspertar's ID 201163 <br />OR CAL OIL I Ci Al D982Kiss � <br />7. Transporter 2 Company Name 8. US EPA ID Number I to T er's 10 . <br />!r, i s <br />d. Does tad Facility Name and Site Address 1 .' US �PA ID Number r¢ awe Fa~s 11) <br />v <br />REFINERIES SERVICE <br />13331 NORTH HWY. 33 K Facility's Phone <br />CAD083266728 (800) 874-4444 <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. h <br />Unit WON* fla <br />No. Type <br />Wt/Vol <br />a. <br />Stme 223 <br />G <br />KAZARDOUS WASTE LIQUID N.O.S. <br />EPA, <br />N <br />- - <br />Oo1TT <br />G FOO <br />tv <br />R <br />b <br />to <br />A <br />EPAt <br />T <br />�;• <br />State <br />p `_ <br />EPAf <br />state <br />' <br />EPAo <br />i-Descriptions <br />for Materials listed Above K. Handfirig Codes for Wastes Limed <br />b. <br />1 <br />RINSATE j <br />C. d <br />h <br />18. Sp ociai Handling Instructions and Additional Information <br />4 <br />}s, <br /># <br />APPROPRIATE; PROTECTIVE CLOTHING AND RESPIRATORS" - t+ <br />- <br />a <br />.a <br />GENERATOR'S CERTFICATION: 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 />4 <br />U! <br />national goVemment regulations. <br />If I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have datermptad <br />to be economically that I have <br />practicable and selected the practicable method of treatment, storage, or disposal currently available to me which minimizes t <br />present and future threat to human health and the aiwirditment;, OR. if I am a small quantity generator, I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that is' available to me d that I coo atfgrd. <br />7 <br />WPrint <br />ypsd me % net a Month Day ,ysar <br />X <br />11 <br />W <br />T <br />R <br />17. Transporter t Acknowledgement of Receipt of Materials <br />�A <br />N <br />ed/T YPed Name � Slpnature Month Clay YaWr <br />� <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Mate <br />iP rials <br />T <br />print ed/Ty me <br />Signature Month Day Year <br />E <br />19. `rapancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Certificatio !fit receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />yr <br />Printed/Ty Name"' <br />_ <br />tore Month Day k earn <br />a A 1 wq <br />MtS <br />8022 A <br />Do Not Write Below This 64/ <br />EPA <br />8700--22 <br />( ,) Frenrlaua editions are obawate. , White: TSDF SENDS THIS COPY TO RIMS WITHIN 30 DAYS <br />° To: F.O. boxQQ, S!o, CA 45812 <br />I r�". <br />