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J State of California—Health and Welfare Agency Form Approved OMB No. 2050-0039 (Expires 9 -30 - Please print or type. (Form designed for use on elite -pitch typewriter). Department of Health Services Toxic Substances Control Division Sacramento, California DHS 8022 A (1 /88) DO Not Write Below This Line EPA 8700-22 (Rev. 9-88) Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS To: P.O. Box 400, Sacramento, CA 95812-0400 UNIFORM HAZARDOUS 11. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas WASTE MANIFEST ocument3No. of kA. is not required by Federal law. 3. Generator's Name a2d Meiling�A�ddress 41 �3/e'��l�JIN/c State Manifest D cu en ber 04848 A �, t / �r1' G B. State Generator's ID 4. Generator's Phone 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID Refineries Serivice I C I A I D 10 18131116 161712 18 D. Transporter's Phone20$ 2-6 42 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID Refineries Serivice 13331 N. HWY. 33 H. Facility's Phone 12. Containers 13. Total 14. 1. 11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) Quantity Unit Waste No. No. Type Wt/Vol a. State NON RCRA HAZARDOUS WASTE LIQUID' EPA/Other G E G N 3 EXE�4PT E A b. Loa ii i t State EPA/Other T,` O R c. State, �''� 2 G lggp EPA/Other, d. CIVViRC7N STH State J PERMIT/SERVICES EPA/aner,. J. Additional Descriptions for Materials Listed AboveIt , Handling Codes for Wastes Listed Above PETROLEUM HYDROCARBON PROX% a b WATER APPROXIC. d SLUDGE APPROX 15. Special Handling Instructions and Additional Information WEAR GLOVES, GOGGLES & PROTECTIVE CLOTHING IN CASE OF SPILL CALL EMERGENCY RESPOE 800'874-4444 OR (209) 892-6742 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. If 1 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 determined to be 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 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 generation and select the best waste management method that is available to me and that I can afford. Printed/Typed Name Signature Month Day Year T 17. Transporter 1 Acknowledgement of Receipt of Ma eriais R A /Typed Name ignat r Month Day Year, �w F i Iti t o C 1� �� GJ Transporter 2 Acknowledgement of Receipt of Materials r Printed /Type Name Signator Month Day Year 19. Discrepancy Indication Space F A C I L I T 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. y Printed/Typed Name - Signature Month Day Year DHS 8022 A (1 /88) DO Not Write Below This Line EPA 8700-22 (Rev. 9-88) Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS To: P.O. Box 400, Sacramento, CA 95812-0400