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e State of Ca)Ilomis—+iealth and Were Agency <br />} Form Approved OM3 No. 2056'-00(Expires 9.30.91 <br />/06¢30 print or type. (Farm designed for use on efite f l_ .itch tvnawdtat) <br />W); <br />M. <br />M <br />a; <br />7) <br />001 <br />, <br />r <br />f <br />f <br />a <br />Department of Health Services <br />Toxic Substances Control Division <br />Sacramento. California <br />DNS 8022 A (1188) <br />EPA 8700 -22 <br />(Rev. 9-88) Previous editions are obsolete. <br />Do Not Write Below Tli UrIe <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest <br />2. Paget Information in the shaded areas <br />1.1. <br />WASTE MANIFEST Document No. <br />of is not required by Federal law. <br />3. Generator's Name and Meiling Address <br />A. Slate M -fest Document Number <br />Western Mercer Service <br />89804395 <br />2735 TEEPEE DR. STOCKTON, CA. 97205 <br />B. State Generator's 10 <br />4.,Generaior's PhoneLOCI ) <br />_ <br />0 <br />S. Transporter i Company Name e. _. US EPA ID Number <br />C. State Trensporter'a ID <br />D. Transporter's Phon - <br />D <br />7. Transporter 2 Company Name e. ; US EPA ID Number <br />E. State Transporter's ID <br />p <br />; <br />F. Trenaporter'e Phone <br />_ <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID -. <br />Refineries Serivee <br />13331 N. HWY. 33 <br />H. Feclllty'a Phone <br />r <br />In <br />t 1. US DOT Description (Including Proper Shipping Name. Hazard Class, and ID Number) <br />12. Containers <br />13. o el <br />Quantity <br />14. <br />Unb <br />1. <br />Waste No. <br />No. Type <br />Wt/vol <br />anon RCRA HAZARDOUS WASTE LIQUID <br />state <br />EPA/01her <br />SK$MPT <br />S E <br />E <br />rY <br />/' <br />R <br />b <br />State <br />A <br />EPA/Other <br />7 <br />� O <br />R <br />� <br />i <br />c. <br />Stets <br />EPA/Other <br />it. <br />Stale <br />i <br />EPA/Other <br />J. Additional Descriptions for Materiels Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />PETROLEUM HYDROCA NS APPROU <br />a. / <br />G <br />b. <br />WATER APPHOX$_ <br />D. <br />a. <br />SLUDGE APPROXI --o. <br />15. Special Handling Instructions and Additional Information <br />NEAR GLOVES, GOGGLES &PROTECTIVE CLOTHING (JUH SITE: TTN IL 13475 Jacktone Rd.Lodx,CA) <br />IN CASE UP SPILL CALL EMERGENCY RESPONES (209) 800-574-4444 0 %d9t-Q742 <br />,e. <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, pecked, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable International and <br />national government regulations. <br />It 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 />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, I have made a good faith effort to minimize my wsets <br />generation and select the beet waste management method that Is available to me and that I can afford. - <br />Printed/Typed Name <br />_ Signature Month , Day Year <br />T <br />R . <br />17.-1nneporlar 7-Ack gemwitetitacelpt of Matedals- <br />N' <br />/ <br />PTYped Name <br />Signature f I - Month-�,Gy Year <br />S <br />P <br />sip} <br />O <br />441ioOrrans0orterr 2 Acknowledgement of Ric of Materials <br />R <br />_ <br />T <br />Prlmed/T ed Name <br />YD <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />y <br />Pda(ad/Typed Name <br />Signature' Monts Day Year` <br />DNS 8022 A (1188) <br />EPA 8700 -22 <br />(Rev. 9-88) Previous editions are obsolete. <br />Do Not Write Below Tli UrIe <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />