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Stats of Csllfomla—Heallh and Welfare Agency gS5q`q $qg(nBt1UCtIDRS OR (19fk "1 PS P B Department of Health Services <br /> . Form Appre-ed OMS No.2050-0039(Expires 9.30.91' @• Toxle Substances Control Division <br /> Please prim or type. (Form designed for use on elite Itch typewriter). and Front of Psf Sacramento,Callfomla <br /> UNIFORM HAZARDOUS I/ Generator's US EPA ID No. Manifest 2. Page 1 Information M the shaded areas <br /> WASTE MANIFEST CAC 0 0 0 1 5 2 4 3 7 ODobu �ntbf 1'4 of 1 Is not required by Federal law. <br /> i (ienx Iq fflER A fid Mailing Address A. Stale Mantle}Document Number <br /> 11(7885 N. Corral Hollow Road V 8 1 9 0 <br /> Tracy, California B. State Generator's ID <br /> 1. Generator's Phone(209 ) 835-6280 <br /> 4 S. Transporter 1 o any Nam t 5. US EPA ID Number C. State Transporter's ID (� <br /> vNj �A •� /rTrenePorter's Phon c_ <br /> 7. Transporter 2 Company Name t e. 9 EPA ID Number E. State Transporter'a <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and She Address 10. US EPA ID Number O. State Facility's ID <br /> JErickson, Inc. <br /> 3a 255 Parr Blvd. <br /> 70 Richmond, California 94801 H. Facility'sPhAT5 235-1393 <br /> -i= ICAD 10 10 19 14 16 16 3 19 12 <br /> LL0 12. Containers 13. Total te. I. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Quantity Unit Waste No. <br /> No. Typo Wt/vol <br /> {U a. State 512 <br /> :)Z G Waste Empty Storage Tanks <br /> 3 € E California Regulated Waste Only I EPA/OtherNone <br /> i, N <br /> E b. State <br /> R <br /> A <br /> T EPA/Other <br /> N Q <br /> R C. <br /> Slats ti - <br /> EPA/Other <br /> d. <br /> Stats <br /> Q EPA/Other <br /> W <br /> RJ. Additional Descriptions for Mef adela Lleletl Above K. Handling Codes for Wastes Listed Above <br /> 6 e, D. <br /> N D �W <br /> C. d. <br /> J <br /> Q <br /> 2 <br /> Q <br /> 15. Special Handling Instructions and Additional Iniormellon <br /> Z <br /> J <br /> J <br /> V 18. <br /> J 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 IeDsled,and are In all respects In proper eontllllon for transport by highway according to applicable International and <br /> y <br /> national government regulations. <br /> Ir 11 I 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 /> Q 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 am a small quantity generator,1 have made a good faith effort to minimize my weals <br /> Q generation and select the beat waste management method that Is available to me en nal I sn afford. <br /> Z <br /> WPdn�eegQ Ne-s / - / SI9ne1 / Month DaY Y�r' <br /> utT 17. Transporter 1 Acknowledgement of Receipt 1 Materiels H/ ' - (/�'`j <br /> R <br /> C N Printed/Typetl Name / gig fur /' Month Day Year <br /> o P // <br /> w O Pegg 2 Acknowledoement of Receipt of Materials <br /> R Printe T ed ems <br /> Q 7 yP Slo ur <br /> Month <br /> E ©th Day Year <br /> = • <br /> 19. Discrepancy Indication Space <br /> Is <br /> ulrasTCUulRt�cfl ptFS�L <br /> ° -IFl�1K HRS gr-iw ��E � ujm D111 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest ex t as n ed In Item 19. <br /> T <br /> y Print*e T pse�Neme�� K at r / Month Day Ye r <br /> DHS 9022 A(1188) tt���`ll V Do Not Write Below T Line 1� OG <br /> EPA 8700-22 White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rey.9-88)Previous editions ars obsolete. To: P.O. Box 3000, Sacramento, CA 95812 <br />