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y� J <br />a <br />�y a <br />Z <br />O <br />3 J <br />U <br />Mil <br />N <br />8 <br />4 <br />N <br />a <br />0 <br />0 <br />Co <br />cc <br />W <br />Z <br />W <br />U <br />W <br />0) <br />Z <br />0 <br />a. <br />V) <br />W <br />cc <br />J <br />a <br />O <br />H <br />< <br />Z <br />State of California—Health and Welfare Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-9 <br />Please print or type. (Form designed for use or elite itch typewriter). <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento, California <br />DHS 8022 A (1 /88) Do Not Write Below This Line <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 400, Sacramento, CA 95812-0400 <br />UNlF®RM MAZAR®®US L Generator's US EPA ID No. Manifest <br />ocument No <br />2. Paget <br />Information in the shaded areas <br />WASTE MANIFEST <br />of <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />980 A <br />B. State Generator's ID <br />4. Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID d <br />D. 7ranaportePs Phonp0q A92-6742 <br />Refineries Serivice D 10$ 1 6 6 2 <br />7. Transporter 2 Company Name S. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone ;. <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />Refineries Serivice <br />I I I I I I_L_LiJ—LI_L <br />H. Facility's Phone <br />13331.N. HWY. 33 <br />Patterson CA. 25363 1 Q1 Al DI 0181 'Al 11616 7121 A <br />2n ACIP -0119 <br />12. Containers <br />13. Total <br />14. <br />1. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste No. <br />No. <br />Type <br />Wt/Vol <br />a. <br />State <br />NON RCRA HAZARDOUS WASTE LIQUID <br />EPA/Other .. <br />G <br />•••. <br />G <br />N <br />N <br />EXEM <br />E <br />b. <br />State - <br />TR!: <br />2 1 �$ §� <br />EPA/Other <br />Q <br />I <br />R <br />C. <br />State <br />EPA/Other,,,, ; <br />d. <br />State <br />ENWRONMENTAL HEALTH <br />EPA/Other. <br />PERMIT/SERVICES <br />J. Additional Descriptions for Materials Listed Above <br />PETROLEUM HYDROCARBON APPRiU� <br />K Handling Codes for Wastes <br />a � <br />Listed Above <br />b <br />WATER APPROX <br />c <br />d <br />SLUDGE APPROX <br />15. Special Handling Instructions and Additional Information <br />WEAR GLOVES, GOGGLES & PROTECTIVE CLOTHING <br />IN CASE OF SPILL CALL EMERGENCY RESPo S <br />800-874-4444 OR (209) 892-6742 <br />16. <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, 1 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 1 have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, if 1 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 and that I can afford. <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />G�� <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />/I opr <br />A <br />N <br />d/Typed Name 1 Sign <br />Month Day Year <br />d <br />S0= <br />K/ <br />P <br />O <br />1 ranap irter 2 Acknowledgement of Receipt of Materials " <br />R <br />T <br />Printed/Typed Name'-, <br />Signature <br />Month D®y Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <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 />Printed/Typed Name <br />Signature <br />Month Day Year <br />DHS 8022 A (1 /88) Do Not Write Below This Line <br />EPA 8700-22 <br />(Rev. 9.88) Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br />To: P.O. Box 400, Sacramento, CA 95812-0400 <br />