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State of Cafifornia—Health and Welfare Agency Department of Health Services <br />F2rm A proved OMB No. 2050-0039 (Expires 9-30- Toxic Substances Control Division <br />` Please print or type. (Form designed for use on a i pitch typewriter). Sacramento, California <br />U) <br />r` <br />I N <br />U) <br />O <br />OD <br />I J <br />U <br />Z <br />ccO <br />+ J <br />U <br />o <br />aD <br />W <br />U) <br />Z <br />0 <br />A <br />U) <br />w <br />cc <br />li <br />O <br />} <br />U <br />Z <br />w <br />0 <br />X <br />w <br />LU <br />LU <br />Z <br />4 <br />LL <br />0 <br />W <br />rn <br />Q <br />U <br />r <br />DHS 8022 A (1 /88) 1 Do Not Write Below This Line III <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />i� <br />UNIFORM HAZARDOUS 171`Generator's <br />US EPA ID No. <br />Manifest 72. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />,,� <br />Document No. <br />of <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address `" `' ' A. State Manifest Dcument Number <br />D.S.S. 8 <br />690 W. C�Lay St:0(>?") `"i; CA. B. State Generator's ID <br />E <br />4. Generator's Phone <br />5. Transporter Company Name 6. US EPA ID Number C. State Transporter's ID <br />g1 <br />"0 p 1 <br />y1 �' .} 9 .. <br />tt ?? ".:' - f'• .Ej 7 D. Transporter's Phone , <br />11,{y .? 2-7628 <br />7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's <br />F. Transporter's Phone' <br />9. ,Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br />p <br />t2ICYCLET�ZC7N OIL, INC. f"I�����I�131►����'�' 0 <br />13331 l� G' 1 F I1 is }' _� H. �Fec7y's <br />pp77Phone <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 />Quantity <br />Unit <br />Waste No. <br />No. Type <br />Wt Vol <br />a. <br />State <br />Waste di`3el/COtitt3Ustible liquid NA. 1393 <br />EPA/Other <br />G <br />E <br />N <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 />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b- <br />RECEIVED <br />Anfin <br />C. <br />d. <br />15. Special Handling Instructions and Additional Informationit"-00 <br />ENVIRONMENTAL HEALTH' <br />PERMIT/SERVICES <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 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 trestmeni, 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, I have made a good faith effort to minimize my waste <br />generation and select the beat waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />Signature /r Month Day Year <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name <br />Signature Month Day Year <br />N <br />SI <br />? r'Ej- <br />7,,,2LLZ <br />s� <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature Month Day Year ' <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <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 />�^ <br />Printed/Typed Name (7. y�«� C Y :� . <br />Signature Month Day Year <br />"1 A 1AA L <br />g <br />DHS 8022 A (1 /88) 1 Do Not Write Below This Line III <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />i� <br />