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Sep-03-97 O3: 21P EVERGREEN - REFINERY 510 796 2559 P.O2 <br /> t <br /> of California—Environmental Protection Agency <br /> Approved OMS No.2050-0039(Expires 9.1496) See Instructions on back of page 6. Department of Toxic Substances Control <br /> Please print or type. Form d - .fjt;us*an eFte(I2-ptch)ypewrrfer. Socromento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2- Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST r• ;� .`, !+ ,_� ) of <br /> 3. Generator s Nome and Mailing Address A. Stan Motufest Document Number .r L „ 9 w 8 1 <br /> Pacific Bell (V„ J� <br /> P.O. Box 5095, Room IN200, San Ramon, CA 94583.0995 S. state Gemerafor's ID <br /> 1. Generators Phone 4110 ?a„ H Y H Q 8 6 0 1 0 1 9 9 <br /> 5. Transporter 1 Company Name / 6. US EPA 10 Number C. State Transporteds 10 <br /> J i..F�l., r'`(�► f:�V}f R t-"PA,-��� I � .3 D. Tronaparter's PI}one <br /> \ i ,F.67 <br /> 4 <br /> 7. Transporter 2 Company Name 8. US EPA 10 Number E. Stoll Tronsportor's 10 <br /> U <br /> F. Transporter's Pharhs <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State 1 <br /> H. Fad 's(sf+orhs <br /> t/"1Z I r I yl tg/'n ` !�-j 7141t Z <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and 10 Number) 12' Containers 13. Total 14. Unit <br /> No. Type Quantify Wt/Vol I. Waste Number <br /> °• Stota <br /> E +'�Ai �� �/�.�/�GrliS L+r'ft;'I,'. ��6�6� I J7 -W l3/r-' �" '" �I EPA/Othef? <br /> AL- <br /> CD N Is. State <br /> E <br /> R EPA/Other <br /> A <br /> co T c S+de <br /> O <br /> It EPA/Other <br /> State <br /> LU <br /> d. <br /> u <br /> EPA/Ofiw <br /> J. Addlitional Descriptions for Materials U0ed A K for Wastes Listed Above <br /> a <br /> W a. b. <br /> C. d. <br /> O 15. Special Handbag Instructions and Additional Information Emergency Response Contact: -,-� 1'1--t <br /> Site Location: 90-7 klk(OJ +I,; I;�yr' <br /> M For instructions on`now fo`crom plete manifest call Pac Bell Env. Mgmt., on (510) 823.6161 <br /> 16. GENERATOR'S TWICATION: I hereby declare that the contents of this consignment ore fully and occurwely described above by proper shipping name and are classified, <br /> packed.marked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> a 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 ro ve the degree I hodetermined tobe <br /> ® economically Practice and Ned I have selected the practicable method of storage ditipastal currently available to me which minimizes the present and future <br /> threat to human heolfh and the environment;OR,if I an a smaLcluontify goner ,1 f ' effort to minimize my waste generation and select the best <br /> waste meted that is available ro me and that I can offord. <br /> PritowT Moore Si® Month Dwy- <br /> V (Q'� <br /> R 17. Transporter I A of R of Matertok Alp <br /> N Pnnted/Typed Monte .SghwNr Month Dap r Yea' <br /> tfPP .r !. <br /> sy 0 18. Transporter 2 A of Receiptof Mahwioh <br /> EPrieted/Typed Name Month Day Yew <br /> R <br /> 19. Discrepancy Ind'aatioo Space <br /> P <br /> A <br /> C <br /> 6 <br /> 1 20• Oester or Certification d t of hazardous materials covered this ma ifed ox as noted in Item 19. <br /> T /Typed No" Signature Month Day Year <br /> • <br /> d g ® s 111-2 <br /> DO NOT WRITE BEL THIS LINE. <br /> C 0022A (1/45) White: TSOF SENDS THIS COPY TO DISC WITHIN 30 DAYS. <br /> 8700-22 To: P.O. Sox 3000, Sacramento, CA 95812 <br />