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Stele at Caldomlo—Environmemal Protection Agency <br /> 'Form Approved OMB No.2050-0039(Expires 9.309e) See Instructions on back or -age 6. Department of m.i.Svbsronces Control <br /> Please p:ml or type. Form designed for use on elite(12Pirc writer. Sum <br /> reento,Cdlfornio <br /> UNIFORM HAZARDOUS 1. Genera or's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST Ir.i ri r.i 01 n (j 1171 P 11 O 'Y of <br /> 3. Generator's Name and Moiling Address A.'State Mani est Document Num /I <br /> 6JOODWARD — CLYDE FEDEPAL SERVICE 326?Q46 <br /> 10370 OLD PLACERVILLE RD. , STE. 104 SACRA!,!ENTO, CA <br /> A. Generator's Ph.. <br /> w (41 R—n9R. 95827 L- ' „ `}'1 L! <br /> m <br /> 66 5. Transporter 1 Company Name 6. US EPA ID Number C. S ale T nsportels t6 '�j/,y <br /> n Ah`ERECP,N VALLEY CAL 0 0 0 1 2 1 1 5 4 ” "r"ar" {PGO} 732-4541 <br /> 3. <br /> 7. Transporter 2 Company Name S. US EPA ID Number E_ Scot T ansporters ID '?4: <br /> �. V <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. St i Facility's ID `e•.s <br /> REFINERIES SERVICE ! 1 C I !+) DI 01f L1161 61712161 <br /> p o 13331 N Ht,!Y 33 y,Ph." <br /> V ¢ PATTERSON, CA 95363 CAD 0 8 3 1 6 8 7 2 ' (800),. 874k4444 <br /> 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) <br /> 12. Cama 3, Total u. Unit <br /> Z Ne. T e Quantity W1/V I I. V.'ane N bet <br /> NOIR' RCR.A HAZARDOUS TASTE LICIUID 223 <br /> 3 G EPA/cher <br /> c E T T G $. . <br /> trdeum Recycling Corporation certifies that the &hove mentioned State <br /> ste(s), more specifically identified by reference to the waste: manile 3t EPA/&her <br /> $ Ai-le provisions of 40CFR261 .6 and 23.4 pursuant to 40CFF 261.3( <br /> K ) hazardous waste generated from the recycling eiforts J PISO EPA/Ocher <br /> W <br /> Z I 51010 i K .Z •: <br /> Z <br /> PETROLEUM RECYC NG CORP RATIO <br /> N - <br /> Z _ ° •.1'wisi F" 'o.. .. 'F Y':. �1�andPmp.Codei forW lis/ed <br /> 0 s7JRIs' 1 n, s' c`1 <br /> J:IAIs ,3 PZ!" <br /> cd <br /> K <br /> 0 15. Special Handling Instructions and Addthonol Information <br /> P USE APPROPRIATE PROTECTIVE GEAR <br /> Z DESIGNATED FACILITY EMERGENCY CONTACT # (800) 874-4444 <br /> = GENERTOR EMERGENCY CONTACT 4(916) 368-0988 <br /> t- <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described obove by proper shipping name and ore clossified, <br /> Qpacked,marked,and labeled,and are in all«speck in proper condition for transport by highway according to applicable federal,stale and international lows. <br /> U <br /> If I am a large quantity generator. I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> "'r economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> ythreat to human health and the environment;OR, t 1 am a small quantity generator, I have made a good faith effort to minimize my wore generation and select the best <br /> a, waste management method that is available to me and that I can afford. <br /> 0 Printed/Typed NameII '' Signature Momh Day �jYear <br /> U LL Z / <br /> ZT 17. Transporter 1 Ackrhowled ement of Receipt of Materials <br /> W i d/Typed Nome SipnvN \ Month Day/ r <br /> z NN L G <br /> W , <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W7 Ninted/Typed Name Signature Month Cloy Year <br /> 0 ■ <br /> N19. Discrepancy Indication Space <br /> 6 F <br /> V A <br /> Z C <br /> I <br /> 120. Facility Owner or rotor Certification of rfdel' of hazardous materials covered Ahi &nil os rimed in Item 19. <br /> T Yea <br /> o�sn +L Si g nature <br /> Y YW Ir` �l/I`Y/F /,- / 1 <br /> DO NOT WRITE BELOW THIS UNE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) \ (Generators who submit hazordous waste for transport ata4stote, <br /> EPA 8700-22 l produce completed copy of this copy and send to DTSC within 30 days.) <br />