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Department of Health Services <br /> Stale of Cnlilomla—Health and Welfare Apancy See Instructions on Back*age C) Toxic Substances Control Division <br /> 5 Sacramento Catilornia <br />' Form Approved OMS No 2050-0036(Expires 9 30 and Front of Page 7 <br /> play. riot or type fForm designed for use an obi-oxx itch typewriter) —7 <br /> 1 Generator a US EPA ID No Manifest 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS of la not required by Federal law <br /> WASTE MANIFEST C Al0 0 0 0 8121 7 2 �a m t A State Mand"88112964 Document Number <br /> 3 Generators Name and Meiling Address 8 811 2 9 6 4 <br /> RIVERSIDE CEMENT CO. — ATTN: MIKE SEIXAS B State Generator a 10 <br /> P 0. BOX 158, Oro Grande, CA 92368 <br /> 4 Generator a Phone(619) 245-5321 <br /> 8 US EPA 10 Number C Slate Transporter s IO <br /> 5 Transporter 1 Company Name D Transporter s Phone <br /> IL C 9 2 1 7 <br /> US EPA ID Number E State Transporter s 10 <br /> 7 Transporter 2 Company Name F Transporter a Phone <br /> 10 US EPA 1D Number G State Facility a ID <br /> 9 Designated Facility Name end Site Address C A D O 181311 6 6 7 2 8 <br /> REFINERIES SERVICE H Facility a Phone <br /> 13331 North Hwy. 33 C 0 8 3 1 6 6 71218 (800) 874-4444 <br /> Patterson, CA 95363I <br /> 12 Contamera 13 Total t, Waste No <br /> Quantity Unit <br /> t 1 US DOT Description(Including Proper Si Ipping Name Hazard Cie as and ID Number) Na Type Wt1 Val <br /> Siete <br /> a 223 <br /> Z HAZARDOUS WASTE LIQUID N.0.S. G EPA/Other <br /> G O O Z T T <br /> N ORM-E NA-9189 State <br /> E b <br /> p EPA!Other ' <br /> A <br /> CO T <br /> State <br /> i O <br /> R c <br /> EPA!Other <br /> w <br /> State <br /> I d <br /> EPA/Other <br /> U <br /> WK Handling Codas}ar Waetas listed Above <br /> J Additional Descriptions for Materials Listed Above e b <br /> TANK BOTTOM WASTE c d <br /> RINSATE <br /> 15 Special Handling instructions and Additional Information <br /> z SEE E.-R.G. 31 <br /> APPROPRIATE PROTECTIVE CLOTHING ''EMERGENCY CONTACT: 800-332-8710" <br /> a to <br /> U <br /> GENERATOR'S CERTIFICATION i hereby declare that the contents of this consignment are lolly and accurately described above by proper shipping nam <br /> and are classified pecked marked end labeled,and are In all respects in proper condition for transport by highway according to applicable international and <br /> national government regulations <br /> If I em a large quantity generator !certify that!have a program In place to reduce the volume and toxicity of weals generated to the degree I have determined <br /> iz to be economically practicable end that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the <br /> Q present and future threat to human health and the environment OR 111 am a small quantity generator I have made a good faith effort to minimize my waste <br /> generetion and select the beat waste management method that is avallable to me and that I can alford <br /> Month Day Year <br /> u printed/Typed Name Signature <br /> LU i <br /> T 1 Transporter 1 cknowledg ant of Receipt of Materials / Month Dey Yeer <br /> R Si re <br /> A Printed I Typed Name <br /> LL S <br /> 0 P 18 Transporter 2 Acknowledgemanl of Roceipl of Materials <br /> O Month Day Year <br /> R Printed/Typed Name Signa r <br /> T <br /> E <br /> 2 <br /> t9 piacrapency Indicetlan t3pe6a / <br /> A <br /> C <br /> I <br /> erel+fr Cal Illcalion of rata+ of hoz daua materiels cover d by a $feat except as noted in Item 19, <br /> 1 20 FaC lily Owner or Op P _� a fh D Year <br /> T !T pad N Signature <br /> Y J P <br /> HS 8022 A 0/88) po N rite Below is Line White TSDF SEND THIS CO DOHS WITHIN 30 DAYS <br /> A 8700-22To P O Box 3 , acramento, CA 95812 <br /> av 9 se)Previous editions are obsolete - <br />