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$Mre el Caiiornlo—EnvirenitleMol NANNoo Agrncy <br /> Form Appreaed WAS Nd.2030-003916pbe,0:094 �/ <br /> See Instructions on back Of e b. Dapamoa <br /> rtof Tmic Suall ouControl <br /> Secramente,Callous. <br /> Hoose purl or tape. Form dapped kr use on este f12 p;kb) <br /> lypewri?er. <br /> I. Generator's US EPA 10 No. Manifest Document No. T. Page I Information in the shedad areas <br /> UNIFORM HAZARDOUS is rat regwmcl by Federal law. <br /> WASTE MANIFEST Ar: l Ort 9 7' "I it "1 6 7 9 1 7 of 1 <br /> 3. Gervratoi s Nome and Mailing Address A. State Manifest Document Number <br /> 0 W.W. MILES _ 92$67597 <br /> he CA jz}I)+'�} B. State Creneretoi s ID <br /> n P.O. BOX 128_q r LOS ALTOS <br /> A. (ienerator'tPhone 1115) 948-'6706 <br /> h _ <br /> --- d. US EPA ID Number C. Stole Trampertor i ID <br /> 3. Irampnrter I Company Name 6 II <br /> NOR CAL OIL AU 'J 82 el 17 12155 D. Trenspada's Phone <br /> (209>667-632 <br /> 7. lramponer 2 Company Name 8. US EPA 10 Number E. State Transpoder's ID <br /> Q <br /> V F Transpoder's Phone -' <br /> st 9. Designated Facility Name—d Site Address 10. US EPA ID Number G. Sroro fsacility's ID a <br /> 2 ENV IRORUR WEST CORPORATION / 1IU <br /> (T)o 13331 NORTH HWY. 33 Ff. Faahty'sPha G�i ve <br /> Ln a PATTERS CA 95363 C F 'I 3 1 6 7 9 r0a —J '�' l <br /> f "'U 12 Containers 13. Toled lel. Ung <br /> y l)Z 11. US DOT Deuripgon(including Proper Shipping Nome,Haxord Class,and ID Number) No — T Quantity <br /> mnl' WI/Vol L Waste Number <br /> (1)2 0 Stssb„s— <br /> t_`� NON—RCR.A HAZARDOUS WASTE LIQUID <br /> U73 G (WATER, & SLUDGE) O 01 T T / I_ FFA/Other <br /> o E <br /> W N b. State <br /> C9 E <br /> FPA/Csther <br /> c R <br /> e A _ <br /> State. <br /> O c. <br /> O EPAj Other <br /> « IT _. <br /> Zd State <br /> w <br /> U EPAjOlhnr _. <br /> w <br /> Z J. Additional }De'scx}pTioas for,Matedahs Wed Above K. Handling Code,far Wasies Listed Above , <br /> O f / <br /> w TANK jBOTTOM WASTE — <br /> « RI.NShTE .y�,, d. <br /> Q15. Special Handling Instructions and Additianol Information <br /> a APPROPRIATE PROTECTIVE CLOTHING JOB SITE: <br /> z "EMERGENCY CONTACT: (209)667-6692” 1145 We CHARTER WAY <br /> = SEE E.R.G. 31 STOCK..TON, CA 95206 <br /> � Id. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described abase by proper shipping name and one classified, <br /> Qpacked,marked,and labeled,and are in all respech in proper condition for transport by highway according to applicable federal,slate and international laws. <br /> U i <br /> If I am a large guenlity '7o oocr, 1 certify That I have a program in place to redswe the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and?hat I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> d threat to human health and she a A,cmenenq OR, if I am a small quantity genemror, t have made a good faith effort to minimize my waste generation and select the beat <br /> N <br /> « waste management meRtod al is awilable To ma and that I ton afford. <br /> O Printed/Typed NameSigne a Month Day Year <br /> 1n Sir- T u2 wu�.w�, � DC1 I <br /> ZT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> m p <br /> C1 Printed/Typed Nome Signature onlh Day ar <br /> N Q <br /> « s <br /> f <br /> g 18. Transporter T Acknowled emenl of Recei 1 0l Materials <br /> uJ Printed/Typed Name nature -Month Day Year <br /> L E <br /> O a <br /> w 19. Discrepancy Indication Space --_-- ---- <br /> ul <br /> U A <br /> Z C <br /> — 1 I _J <br /> l <br /> I M FocillN Owae. a Orator C•nf ration f cwt es haxa.dws muter els co d b:� h ma fee_der s d 1-n gem 19. __ _— <br /> T I P ted//typed Name / 3 g)otu . M)amh Day Year i <br /> Y Ci T �=i � �rrf! ���%1/J •i' ` / Y�l/ I,'/�_/ ✓,G ��// /rj� � / ��/ I C� � r Yi � �! , <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC P,022A V;921 <br /> EPA 97Vry-22 <br />