Laserfiche WebLink
State of California—Health and Welfare Agency Department of Health Services <br />Form Approved OMB No. 2050039 (Expires 9-30- Toxic Substances Control Division <br />Please print or type. '(Form designed for use on elite pitch typewriter). Sacramento, California <br />UNIF®RM HAZARD ®U <br />1. Generator's US EPA ID No. <br />Manifest <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFESTDocument <br />No. <br />of <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State Manifest D cNum er <br />CAMEPA' S CAR WASH <br />gent <br />89 <br />456.42 <br />N. HUNTER ST.StoCkton, CA. 95203 <br />B. State Generator's ID <br />4. Generator's Phone( 209 948-3636 <br />5. Transporter 1 Company. Name 6. US EPA ID Number <br />C. State Transporter's ID <br />Ir <br />Refineries Serivice CAD 7 2 8 <br />D. Transporter's Phone20 2" 7 <br />I 10 18131116161 <br />N <br />'n <br />CP <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />o <br />1 1 1 1 1 1 1 1 <br />co <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />a <br />Refineries Serlvice <br />H. Facility's Phone <br />U <br />1.3333 N. HWY. 33 <br />a <br />Patterson CA. 95363 <br />�. <br />209 892-6T42 <br />X <br />it 0 <br />12. Containers <br />13. Total <br />14. <br />t. <br />No. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste " <br />" <br />J <br />Ni Type <br />Wt/Vol <br />00 <br />a. <br />State <br />z <br />NON RCRA HAZARDOUS WASTE LIQUID <br />�'"� <br />EPA/Other <br />i, �,` y."�ai° <br />t <br />G <br />T <br />- E <br />b.R <br />iu <br />UState <br />Q <br />53 <br />Go <br />T EPA/Other, <br />v <br />O <br />1 <br />v <br />R <br />C. <br />State " .. . <br />8 <br />EPA/Other" <br />ENVIRONMENTAL. HEALTH <br />w <br />d. <br />State <br />f - <br />Z <br />» , <br />Int <br />W <br />V <br />W <br />co <br />J. Additional Descriptions for Materials Listed Above <br />K Handling Codes for Wastes <br />Listed Above <br />0 <br />PETHOLEU14 HYDROCARBON APPROXA ZV " <br />a <br />b. <br />C0 <br />_ � <br />WATER APPROX <br />C. <br />d. <br />°C <br />SLUDGE APPROX'" <br />a <br />Z.r <br />O <br />u <br />15. s Anformation <br />aOLOVESInstructions (PROTECTIVE <br />RGOGGLES & CLOTHING <br />IN CASE OF SPILL CALL EMERGENCY RESPONES <br />3oa-8T�I-1444 OR (209) 8924742 <br />J <br />J <br />'a <br />U <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 />J <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 />IL <br />national government regulations. <br />If 1 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 />pto <br />be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />} <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 />U <br />generation and select the best waste management method that is available to me and that I can afford. <br />LuPrinted/TypeddNName <br />tL <br />Signature Month Day Year <br />W <br />WT <br />R <br />1-f. Transporter 1 Acknowledgement of Receip f Materials <br />Z <br />A>Printed/Typed <br />Day Year <br />Name / Sin Montgu; <br />LL <br />O <br />N <br />SC <br />(J] <br />!,2 ® <br />W <br />p <br />Oorter <br />2 Acknowledgement of Receipt of Materia <br />TPrinted <br />/Typed Name <br />Signature Month Day Year <br />U <br />E <br />Z_ <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 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 />