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(,/c{/ Department of HealthSeNlcea <br /> State of Cellfornla—Health end Welfare Agency y� • / Sfle hY:•tr,.it:tiopp of- rack of ^mgm 6 Toxic Substances Control Division <br /> Form Appruved OMB No.2051)-0039(Expires 9.30.91) and F10¢1. D( RTgR Sacramento,California <br /> Pie as print or type. (Form designed for use on elite(f 1 typewriter). <br /> 1. Generelor'a US EPA ID No. Manifest 2. Pelta 1 Inlormetlon In the shaded areae <br /> UNIFORM HAZARDOUS Document No. of a not required by Federal few. <br /> WASTE MANIFEST CAC 0 0 0 1 5 2 4 3 7 0101010 2 1 <br /> 33 sen el s Na a end Meiling Address A. State Manifest Document Number <br /> K !Y �ru CTcing 8 81977 <br /> 1785 N. Corral Hollow Road a State Generator's 10 <br /> Tracy, California <br /> a. Generator's Phone g09 ) 835-6280 <br /> b 5. Tr ep er 1 ompany Name e. US EPA ID Number C. Stale Transporter's ID 1y <br /> D. Transporler's Phone �3 <br /> N <br /> � 7. Transporter 2 Company Name B. U3 EPA ID Number E. state Trenaporter'@ ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number O. state Facility's ID <br /> J Erickson, Inc. <br /> 'a 255 Parr Blvd. H. Facility's Phone <br /> 1.0 Richmond, California 94801 415 235-1393 <br /> _j= D 0 0 9 4 6 6 3 <br /> —M 12. Containers 13. Total td. 1. <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> 7a No. Type Wt/Vol <br /> w a. stere 512 <br /> DZ G Waste Empty Storage Tanks EPA/Other <br /> �€ E California Regulated Waste Only 0 Z bC. None <br /> E b. Slate <br /> N R <br /> A EPA/Other <br /> ro T <br /> R o. state <br /> g EPA/Other <br /> w e. state <br /> r <br /> Z EPA/Other <br /> L) <br /> ZJ. Additional Descriptions for Materiels Listed Above K. Handling Codes for Wastes Listed Above <br /> Q e. D 1 e. <br /> N <br /> w <br /> C. e. <br /> J <br /> Q <br /> Z <br /> Q <br /> Q 16. Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> J <br /> J <br /> U /8. <br /> GENERATOR'S CERTIFICATION: I hereby declare 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 by highway according to applicable International and <br /> c. national government regulations. <br /> m <br /> M It f am a large quantity generator,I certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> 0 to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,If I em a small quantity generator,I have made a good faith effort to minimize my waste <br /> U generation and select the beet waste management method that Is available to me and t c Ilortl. <br /> Z Printed/Typed Nem Signature Month Day Year <br /> M �Roa�� s oic yr' o <br /> wT ll. Transporter 1 Acknowledgement of Receipt of Materiels <br /> Z R _ <br /> 8 Ince T�.a'/L m� �� 51 r Month Day Year <br /> ILA±27 ! t <br /> P <br /> O 18. Transporter 2 Acknowledgement p f Receipt of Materials <br /> w <br /> UT Printed/Typed Name 1. Signature Month Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space '•t' <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials cover by this manifest except as n&jA hem 19. <br /> T <br /> Y Prin yped Name sign Monf Day Year <br /> ISr3AJL .S�pLK^ % 4Z . <br /> DHS 8022 A 1188) Do Not Write Below This Line <br /> EPA 870G-22 WNtc: TSOF SFNDS THIS COPY 10 DOHS WITHIN 3C DAYS <br /> (Rev.9-88)Previous edition@ are obsolete. <br /> Tbr P.O, R:+x 3000. SDcrr,menfo, CA 93E 12 <br />