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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30.99) <br />Please primo or type. Form designed for use on elite (12-pil&ewriter <br />See Instructions on back -4 age 6 <br />Department of Toxic Substances Control <br />Sacramento ('nl:fnrnin <br />r4 P <br />` Generator's US EPA ID No. Manifest Document o. <br />UNIFORM HAZARDOUS <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />aft <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />X Stateanifest Document Number <br />Jim Thorpe Oil, Inc. <br />B. State Generators ID <br />' <br />1 <br />P.O. Box 33'7' Lodi, CA 95241-0357 <br />4. Generator's Phone (, ) 09 ,„ <br />173 <br />I <br />t <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />t <br />i <br />tt7� <br />RICOki i a�ae-�LLICa�:Yi A' ST vim y 'T a� v <br />D. Transporter's Phone 80,0-732,41645 <br />7. Transporter 2 Company Name $. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9. Desi noted Facili Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />BANK OIL T TRANSFER t <br />1�4�yt <br />A S O 03 1 J d� 3 9 <br />M <br />a9��v}t4P�bec�gLp�ikUS ROAD <br />D <br />H. Facility's Phone <br />y �p 4 <br />I E.f5.6�ANK CA d A t &J t is <br />'E <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />- <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />1. Waste Number <br />No. <br />Type <br />__ <br />#Od-dOiR i3L1 Wi�ai �.I11P0 <br />Stare <br />221 <br />G <br />r l «.'Tf» :3 j <br />*L! d <br />"; ; <br />a <br />EPA/Oihe' i <br />E <br />.e �. ,- <br />N <br />b. <br />State <br />E <br />R <br />VJA4eL f' - Sys -�'Ke -,o`er <br />EPA/Other <br />A <br />T <br />C. <br />State <br />O <br />EPA/Other <br />R <br />d- <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />OILY WATER <br />b. <br />a. 01 <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />GLOVES <br />EMERGENCY PHONE 209-4367-88,157 <br />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, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If I am a large quantify 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 to be economical[ y <br />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 <br />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 <br />available to me and that I can afford. <br />r <br />^Printed/Ty ed Nome r <br />Sig It <br />Month Day Year <br />jl� <br />T <br />1 Transporter I Acknowledgement o Recei t eMaterials <br />R <br />A <br />Printed/Typed Nome <br />Signature <br />Month Day Year <br />P <br />�2 <br />0 <br />18. Trans orter Acknowledgement of Receipt of Materials <br />T <br />Printed/Typed Name % <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1 /99) <br />—22 <br />EPA 8700 allow GENT ATOR RETA;NS <br />