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S a of Cahfornio—Environmental Protection Agency Sae lnstruttwns on back of page 6 Department of Toxic Substontas Central <br /> Form Approved OMS No 2050-0039(Expires 9 30-96) Sacramento California <br /> Ptease print or type Form designed for use an atite(127ptch)typewriter <br /> 1 Generators US EPA Ip No Manifest Document No 2 Pogo 1 Information m the shaded areas <br /> r is not required by Federai law <br /> UNIFORM HAZARDOUS ,# -� j, `� � r , t q <br /> WASTE MANIFEST <br /> 3 Generator's flame and Mailing Address j f r y r,, f A Stafo AAamfes49Doc� Number <br /> j fi'Y".. 1' fj`�/of 5 2 7 9 <br /> fI � [ r7 6 State Generator's ID <br /> 11-001, <br /> 4 Generator's Phone, ) �s 70-717j/ r L!` -r 7 % F <br /> 0 5 Transporter 1 Company Name 6 f15 EPA ID Number C State Transporters ID � 5 «; <br /> _ D Transporters Phone <br /> 1 .t,+i�Y i ICIFUR YFL'S CORP. <br /> Cl Al j i 3 () 9 ... /a <br /> Q 7 Transporter 2 Company Name <br /> 8 US EPA ID Number E State Transporters ID <br /> V I I I I I I I I I F Transporter's Phone <br /> Q G State Fociiitl/s ID <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number <br /> 7 PITC PArXERSON, INC. <br /> 13331 N. �'. 33 H Faaldy's Phone <br /> PATTERSON, 'CA. ;°5363 C AlD 018131 1161 6 7 2 $ HOO 4--'44 <br /> 12 Containers i 13 Total 14 Unit <br /> Z 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> State 223 <br /> 3 NON RCRA RAZARD(3ij.Si. 'WASTE LIQUIDf� EPA/011ier <br /> f <br /> 7r G Q C I T T <br /> o TP( G <br /> E State <br /> Cc N b <br /> 4 E EPA/Other <br /> v R <br /> OCts <br /> A Sta <br /> m T <br /> O EPA/011ier <br /> tY <br /> iu <br /> � Stats <br /> Z d <br /> (Wj EPA/Odner <br /> w <br /> v7 <br /> 1 Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> r,r <br /> a � b <br /> LU [CATER 6 OIL ' <br /> c d <br /> Q <br /> Z <br /> 15 Special Handling Instructions and Additional Information <br /> a 24 FR. EMERGENCY COPTACT: FRC #1-(600)-P,74-4444 <br /> Z 24 HR. EMERGEM RESPONSE. CHEM TEL IF-C. #1--(800)-2.55-3924 <br /> = APPROPRIATE PROTECTIVE CLCTRIi:G b RESPIRATOR. <br /> 15 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are cksssdied, <br /> Vpacked,marked and labeled and are in oil respects in proper condition for transport by highway according to applicable international and national government regulations <br /> 1 if I am a large quantify generator I cerhly that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> d economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future <br /> u7 threat to human health and the environment OR, if I am a small quantity generator I hove made a good faith effort to minimize my waste generation and select the bast <br /> 0 waste management method that is available to me and that I can afford Y- r V` .z> Mo�� DW <br /> f _ <br /> Printed/Typed Name r' Signature <br /> tZT 17 Trans iter 1 Acknowled errant of Recei of Materials ''t � <br /> R Signatures {f <br /> 0A Pr /Ty ed ane f` )air, Cleo <br /> LU 5 <br /> P 18Trans rtor 2 Acknowledgement of Receipt of Materials f <br /> to R Signature <br /> Day Year <br /> U- T Printed/Typed Name <br /> 0 R <br /> U.1 19 Discrepancy Indication Space <br /> in <br /> Q F <br /> V A <br /> Z C <br /> — I <br /> L <br /> I 24 Facility Owner or Operator Cerhficntion of receipt of hazardous materials covered b This manifest except as noted in Item 19 <br /> Month Day Year <br /> T Printed/Typed Name Signature <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (9/94) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />