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Stale of Caldomia4+4eanh and Welfare Agency Department of Health Service <br /> Form Approved OUS No 2056-0039(Expires 9- • Toxic Substances Control DivlsK <br /> Please pito)or type. (Farm dssViwd for use on eats(f2-pitch typewriter). 7-195-01 Sacramento,Caiiforn <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Mantles, 2. Page t <br /> Document Mo, IMorrnalion h the shaded areas <br /> WASTE MANIFEST of Is not required by Federal law. <br /> 1 3. Generator's Name and Mailing Address. AL State Maflffest DocueflaM N <br /> TRI VALLEY GROUTERS PLNT T <br /> 6200 NOWELL RD b, state cianerators ID <br /> HDRNTDN GA 9568b <br /> t. Generator's Phone 209) 794•-2303 <br /> ,R b Transporter t Company Name G. US EPA ID Number G. Stale Tranopww's ID <br /> R D. Transporters Phone <br /> 20d SAS-4011N <br /> 7. Transporter 2 Company Nares a. US EPA ID Number E. Slele Transporlees ID <br /> F. Transporters Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Stats Facility's ID <br /> SAFETY CORP. 7-18�--01 <br /> 5050 SALIDA BLVD l+- Fsc&ty'aPhone <br /> CAT poc1? <br /> 12. Containers 13, Total tit. 1. <br /> t t. US DOT Description(Including Proper Shipping Name,Hazard G➢ass.and ID Number) Quantity Una Weal*No, <br /> �y No. Type Wt1Vo1 <br /> 0) v a WASTE PETROLEUM NAPHTHA Stale 741 <br /> COMBUSTIBLE L14UID UN1255(D00I ) <ERG 027? DM P EPAr4lher 080 i <br /> N <br /> E b. Stats <br /> R <br /> A <br /> T EPA/Othx <br /> N q <br /> QQ� R c_ Slate <br /> EPA t Other <br /> Ujj d. state <br /> U <br /> EPhrOther <br /> W <br /> yZ J. Additional Deecriptlana for Materials Listed Above y K. Handling Codes for Weals&Listed Above <br /> 0 ■. b. <br /> 14 AND Mill <br /> tl <br /> rA <br /> tlu <br /> pt c. d. <br /> i <br /> Z �} a . .. o �•; <br /> 0 <br /> I^ 15. Special Handling Instrucliona and Additional Information <br /> ¢ 9033 15300958 470212 7-185--01-3077 01 <br /> W EMLL-PGENCY RES`P01-708-886-4660 <br /> � <br /> J SKDOTO A: 501 B: C. D: <br /> J <br /> U <br /> GENERATOR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable intemational and <br /> d national government regulations. <br /> to <br /> Q 111 em a)sopa Quantity generator,I certify that I have s program in pSece fo reduce the volume and toxicity of waste generated to the degree 1 have determined <br /> O to be economically practicable and that t have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> >- present and future threat to human heahh and the environment;OR.if I am a small Quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available 10 me and that I can attord- <br /> Z <br /> W PrintedrTyped Name / / s Signature i Month Day Year <br /> w r <br /> / 1 r — -� -.- / �l-•�� -.. <br /> WTR 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z A PrinledfTyped Name Signature Month Da Y r <br /> ¢ N <br /> LL s Noel 1loornton <br /> P <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> III <br /> N - <br /> ¢ p Printed'Typed Name Signature Month Day Year <br /> U E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L <br /> 1 20, Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in nem 19. <br /> T <br /> V Printed,Typed Name Sgnsfure Month Day Year <br /> Clark E. Hill <br /> DHS 8022 A(1188) Do Not 'Write Below This line <br /> EPA 8700--22 <br /> (Rev. 9-88)Previous editions are obsolete, <br /> Yellow: TSDF SENDS TWS COPY TO GENERATOR WITHIN 30 DAY'. <br />