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' Slate of Callfomla—Heatth and Welfare Agency See Instructions on Ba Department of Health Services <br /> Form Approved OMB No 2050-0039(Expires 9 30 91) Back <br /> .�� Of pa$t3 ti Toxic Substances Control Division <br /> Pleap�s-yrinl or lype (Form designed for use on elite(12 pitch typewriter) and Front of Page 7 Sacramento,California <br /> UNIFORM HAZARDOUS 1 Generalors US EPA ID No Mamlest 2 PeQe 1 Information In the shaded areas <br /> ' WASTE MANIFEST A C O 0 0 $ ] 2 �° m t of Is not required by Federal law <br /> 3 Generator a Name and Mailing Address A Stale Mamie Document Number <br /> RIVERSIDE CEMENT CO. — ATTN. MIKE SEIXAS X8112964 <br /> P. 0 Box 158, Oro Grande, CA 92368 B Stale Generator a ID <br /> 4 aeneralora Phone(619) 245-5321 <br /> LO 5 Transporter 1 Company Name 8 US EPA IO Number C SIMS Transportar s ID <br /> I LC 9 2 1 7 D Transporter a Phone r <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E Slate Transporter's 10 <br /> 0 F Transporter a Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility a ID <br /> REFINERIES SERVICE C jAjDjOL8j3j1j6j6L7f2j8j <br /> 13331 North Hwy. 33 hl Facility's Phone <br /> nz Patterson, CA 95363 C 0 813111616171218 (800) 874-4444 <br /> taI <br /> 11 U3 007 Description Can iners 13 <br /> on(including Proper Shipping Name Hazard C1eas and ID Number) OuaTotnalityl 14 Unit Waste No <br /> No Type WI/Vol U a Slefs <br /> Z ¢ HAZARDOUS WASTE LIQUID N.O.S. 223 <br /> E ORM—£ NA-91890 0 1 T T G EPA101her <br /> E b <br /> a R State <br /> m A <br /> T EPA <br /> /Other <br /> 0 <br /> R c <br /> State <br /> m <br /> EPA!Other <br /> d <br /> State <br /> 41 <br /> U EPA/Other <br /> J Additional Descriptions for Materials Listed Above K Handling Cedes for Wastes Listed Above <br /> LU TANK BOTTOM WASTE a b <br /> RINSATE G d <br /> 15 Special Handling instructions and Additional Information <br /> Z SEE E.R.G. 3T <br /> APPROPRIATE PROTECTIVE CLOTHING "EMERGENCY CONTACT: 800-332-8710" <br /> J <br /> G 18 <br /> GENERATOR'S CERTIFICATION f hereby doctor*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 bj highway according to applicable International and <br /> national government regulations <br /> rn <br /> If 1 am a large quantity generator I certify that T have a program In place to reduce the volume and toxicity of waste generated 10 the degree I have determined <br /> to be economically practicable and that I have selected the practicable method of treatment, storage or disposal currently available to me whlch minimizes the <br /> present and future threat to human health and the environment OR It am a small quantity generator I have made a good faith effort to minimize my waste <br /> generation and select the beet waste management method that Is available to me and that I can afford <br /> Printed/Typed NameMonth Day Year <br /> try f1� Signature ` <br /> I/an2- <br />� 7 <br /> T 17 Transporter 1 cknowtodg ant of Receipt of Materiels <br /> R <br /> A PrfntedlTyped Name <br /> N Si re Monfh Day Year <br /> LL S <br /> PO 18 Transporter 2 Acknowledgeof <br /> m+nt Receipt o!Materials <br /> T Prinied/Typed Name Signe r <br /> Month Day Year <br /> E <br />_z <br /> 19 Discrepancy Indication Space <br /> F ` <br /> A <br /> C f <br /> r <br /> I 2O Facility Owner or Operator C+� Illeallon of receip of haz dour materials cova�d by s �teai except an noted in Item 19 <br /> T !T ped N <br /> Y ��t BeQnatura o rh 0 Year <br /> S 8022 A(1,88) `- <br /> A 8700-2s Do N rite below Is line White TSDF SEND THiS CO DOHS WITHIN! 30 PAYS <br /> ev 9 88)Previous editions are obsolete <br /> To P 0 Box 3 acromento, CA 95812 <br />