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State of Ealifornio—Environmental Protection Agency <br />Form Approved OMB Na, 2050-W39 (Expires 9-30-99) See Instructions on back oae 6. Department of Toxic Substances Control <br />Please prin'f or type. Farm designed foPuse on elite (12•pitch) writer. Sacramento, California <br />O <br />LC <br />n <br />CV <br />•n <br />CP <br />O <br />O <br />co <br />r <br />J <br />r� <br />4 Q <br />3�Z <br />7 Q <br />0 <br />Q <br />V <br />Z_ <br />S <br />3 <br />N <br />O <br />O <br />co <br />N <br />0 <br />CD <br />co <br />Uj <br />W <br />F - <br />Z <br />W <br />V <br />W <br />Ln <br />0 <br />h <br />W <br />Q <br />Z <br />0 <br />a <br />Z <br />W <br />s <br />J_ <br />Q <br />V <br />J <br />a <br />N <br />rel <br />V <br />Z <br />w <br />0 <br />cW <br />W <br />U- <br />0 <br />W <br />N <br />Q <br />V <br />Z <br />DO NOT4WR*BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />UNIFORM HAZARDOUS <br />1. Generators US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />is not required by federal law. <br />WASTE MANIFEST <br />C A L 0 0 0 0 4 5 9 3 G 2 4 5 7 g <br />Of <br />3. Generator's Name a d.MQQ}}'��ipg Address <br />i,3uIC- STop �'ir425107474 <br />A. State Manifest Document Number <br />4567 ENTFRPRISE 4T. <br />B. State Generator's ID <br />> nt OWT, CA 94538 <br />A. Generator's Phone ( 2 0 9) 4 61- 63 3 7 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID Reserved.] <br />SHOP HAZARDS SOLUTIONS C A 0 0 0 0 6 4 6 4 9 7 <br />D. Transporter's Phone <br />(80Q} 74b-7449 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporters ID [Reserved.] <br />F. Transporter's Phone <br />Name Address 10. US EPA ID Number <br />G. State Facility's ID <br />�and <br />•�,Site <br />rr9•...•��+D.g`esigZ�nay�ytteiid;;s/F•��atrc�ii,llait��y [� <br />i71:aL'�`.Iid'Sf4CHO t��l..�'..LJ�..*VA, LLC. <br />1 1 S G S WHITE ROCK RD • <br />H. Facility's Phone <br />RANCHO CORDOVA, CA 9574 CA D 9 8 0 8 8 4 i S 3 <br />(916)351-0980 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. UnitNo. <br />Wt/Vol <br />I. Waste Number <br />Type <br />a- fLiza31dctua vastef solid, n.o.e.t 9, NA3077F III <br />State 5 <br />(GASiOLINErBENZEIstL". (DO18) <br />EPA/0" <br />G <br />001 <br />DM <br />0035 0 <br />PtllEk <br />E <br />N <br />b. <br />State <br />E <br />R <br />EM r. r, Ar <br />EPA/Other <br />`[ ": <br />ti.+ <br />T <br />0 <br />i. <br />pelrmits for, and will acdept <br />State <br />EPA/Other <br />R <br />the waste this <br />d. shipping. <br />State <br />EPA/Other <br />J. Additional Descri tions for Mb ials Lis al Above <br />K. Handling Codes for Wastes Listed Above <br />a), II>' ._' G"OLTNE PUMP Flim, -. <br />WSES & Imsaw <br />a .. -. b. <br />,. <br />C. <br />d. <br />15. S tai Handlin Instructions and Additional Information <br />APPk{}PRIA'i , PROTECTIVE CLOMNG JOB SITE: 205 WEST LOCKFORD, LODI, CA <br />"EMLERGENC°Y CONTACT-. (800) 746-7449- <br />5EE E.R.G. PAGE # 271 <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 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 to be economically <br />proctico6le 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 smaquantity 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 />Pr' ted/Typed Name <br />Signature <br />Month Day Year <br />Of <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />WS <br />Printed/Typed a <br />Signature <br />Month Day Year <br />lel"?l <br />LS1016 <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month. Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />L <br />1 <br />20. FacilityOwner or Operator Certification of receipt of hazardous material covered by Ilkis manifest xce t as noted in Item 19. <br />T <br />Printed/Typed Name �Q <br />S a <br />Month Day Year <br />DO NOT4WR*BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />