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• <br /> Please print or type.(Form deslgnodfause on el8e(12•pi(s>ti)Vpeyvriter.) Foam .Oh1R No.205OV39 <br /> UNIFORM NA2Af;00UR ha.M MrlD WF, � ZPirr l of 3 EirergenclRaspome Phoe MIT IT ndk mbar <br /> WASTE MAN�EBT C A.1._-0002 h 9 3i 7 5 1 (3 00)A24-936o, 013 8M 9 7 rj'7 JJ K <br /> s.ranera��tyshame up G. Address Canamtola SitIMMISIdddkfeM8len miftaddaI -- <br /> r'll:lt Pl faULl.N$t� <br /> 3921 CI.ARK OR 3927 CLARK OR <br /> 5WIVON OA 96206 STOCKTON CA 96206 <br /> Geneaaaya Plsorm: 51.5 X85.2000 <br /> 8.TransWer f CompanyHr m t US.EPAIO Number <br /> A5011VP.NV11i0NMENTAL SERVICES :A 6 018 2 f 7 6 <br /> 7.TmmpaMrlConspanyName US.EPAID hander <br /> S.Dex'gnated Fao3ty Nona andSHekkkau US.EPAIO Number <br /> ON D1 •0y <br /> 7 i50 11E4RONIfdAY <br /> DIXON CA 95620 CaT0a0412602 <br /> F sPhma: (7071693-F008 <br /> ga. us.O.S.DOTDevAp8on(MrlodryPromf Sh'ppng Name,llazardVw,DNuminr, Ie.Coma!nem nw 12.U.1 <br /> WA am1PalAkgOroW(,fany)) No. Type r,)turey IriMA. 13.111mleCodes <br /> oA?ny,orua uwZ4F^OUS."1°STr,I.Iv-10IVIS`.D 01,/'41.YED Oil", 001 )T �� 221 j <br /> z i <br /> z 2. i <br /> I <br /> 3. <br /> I I <br /> 4. TI <br /> I <br /> I <br /> s <br /> W. RaidDp MSMsrEmsaMAddl'onal I <br /> NAERGH 981 111 PROFILE 1081. DK100189 EMERGENCY C NT CT.CF RFC 1-3O0-b' -9300 ' <br /> aD01flONAI.,fi'A 0 TIC&-9A'L• .NONF ' APPROPRIATk PtASONA PP.WO, IW.VOUIPM01 j <br /> Is. GENERATOR'SIOFFERORSCERRFICAIIDN:Ihoebydeclare Brellhe contanU of asfonSlg !are(Wdya as mlmy acrked abore hylbe lsmpNSh. rrome,Woa dassifed,pa(kaged, <br /> marked and la Pacarded,and aro is al respects M PmpercoMSonfa g��paorllaccom al caMelyder fm lardn lonalgarelrurer3alaegJa' .IlexpoaleHpmem aMlamthe Pdmary , <br /> Exporter,!. til almemeMsol 1 '9nmenlfofsbnn to Na termso eTtf21!axAedE AA eedg to 1 <br /> I arty.. Me 5lo mn'nrxal'ons men Gfidln 40 CfR261.27(al dlamaWrgo4 nGygen ro' )aha J amasMI r9lygmm aWa. <br /> Genera M(ar yb n yped Name / 4 0./onN Day fear <br /> fly lJ � j <br /> I6.ImemefCnal SR. is <br /> bnpalb US. ❑Export pan D.S denlryhzk <br /> ? Transpodusjsuloa(f xports any): kar'rp U.S.: <br /> 17.Tranpak AEvaNedgmenlolRIfda's <br /> Tfa i dmedrryped Name Smm ManM pay yea <br /> r6i7 (`l D/ <br /> Tra 2 yped ame Sgnalore Month Day Year ! <br /> I <br /> I <br /> } 18.Uwapancy <br /> fea.00.saepancy1M'rau.Spare ❑ ❑ l <br /> QuanGy ❑iypa ❑Res'due Pan5l RepxfW ❑ <br /> n fm 6te;ectbn i <br /> r <br /> Grandest Refererca Number. i <br /> 18b.Alternate PacAty(a Generatof) U.S.EPAID Number <br /> I <br /> v I <br /> LL FaorVs Phmo: <br /> s 18c.SIIIwhum of Marinate Fari'dy(a Generator) Monty Orr Year t I <br /> ` 1 <br /> yis.llazar 5 as meaPitholCooler(i.e..xa'esforhaed"wale beaWepl,&sposai.and rec)%*gsys!ems) 1j <br /> p 1. /: 2. <br /> 20.Designated FWA Oanera0p .r.CaeScafanoframptI smatedilscrosredbyeemardeslexceplas <br /> Pfin edN w �` Sidnaiule Y <br /> 'V/_L � GJ/ <br /> EPAForm8100.22(Roe3-O5) Previous editions ate obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />