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)tate of Lalttornlo—tnnronmentat Frolection Agency <br /> r �ved OMB No.2050-0039(Expires 9-30-991 See Instructions on back of page 6. <br /> Pease pnnl or type. form designed for use an elite f 12-pitch writer- 9 605195 Department of Toxic Substances.Cor. <br /> Sacramento,California <br /> t enerotor's US EPA ID No. Manifest Documen 2. Page 1 information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST C A 11101810101214171917 8 Z O 9 5 of 1 is not required by Federal law- <br /> 3. Generator's Name and Mailing Address <br /> PACIFICa 41�e$' a cu �egfslmbxer s, <br /> p M BOX X309 ROOM #3D( cjia } <br /> ffyy�a p •Yty <br /> ' 6AN $ANON CA 94583 {�L 1$Z 3— 6"b b <br /> � 4. Generator's Phone <br /> �L�� <br /> rlI s�a Pel%RWMORTATION & b. US EPA ID Number C o e ?pn ppslgr'}111 f2e`ser b r <br /> CP TT i <br /> Q REHMIAiTION, INC. C A D O 6131-914171919 6 r e F <br /> One <br /> CP �a 008 1196 <br /> J 7- Transporter 2 Company Name 8. US EPA ID Number , SfiTt4 s� #Eeseiv`e"d$]r+''3` } <br /> 4_ Des <br /> ignaled Facility Name and Site Address t� 10. US EPA ID Number .�-y� A rzr <br /> Rom i L-1 f 1 t �tTsw5a rj, <br /> Z <br /> f3Dx <br /> =2&0t Pale Alrliiil <br /> y tJ 4 16.1 <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers .. M 13. Total <br /> U a. No. Type Quantity Wt/Vol Ct a u <br /> 9 s WASTE FLAIMLE LIQUIDS, N.O.S.(GASOLINE, DIESEL), 3 UN1993 PGII <br /> 3 G RO (11018( E101(128) T T <br /> ((h <br /> o N b'00 <br /> co E <br /> t <br /> �I R <br /> A <br /> x F FQ <br /> oT g r <br /> co O <br /> R <br /> w d. <br /> .ErTyF4Tg <br /> LU <br /> `d:: •s 5`v r� s�t ..%6. A � s. a4� �., -�-sr�•.' ,� - c ro � ��.F' <br /> LU <br /> 7 <br /> O 15. Special Handling Instructions and Additional Information t <br /> z ENUGEACI QESPONSE CALL (800) 947-7701 `T� At�aare55 �Lj 'm' Avg <br /> 16. GENERATOR'5 CERTIFICATION: I hereby declare that the contents of this consiynmenl are fully and accurately described above by proper shipping name and are classified,packed, <br /> V <br /> marked,and labeled,and are in all respects in proper condition for transport 6y highway according to applicable iniernalional and notional government regulations. <br /> J <br /> If 1 am a large quantity generator,i certify that I have a program in place to reduce the volume and toxicity all waste generated to the degree i have determined to be economically <br /> v� practicable and that 1 have selected the rracticu6le method of Ireatment;storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O <br /> C) available to me and that I can afford. <br /> >- Printe Typed Name Sig Lure <br /> U t - Month Day. Year <br /> Z T . o f 1. `—. Z C <br /> (y R 17. Transporter I Acknowledgement of Receipt of Materials <br /> iw Signature s I P led/Ty �d Name - Si <br /> 1 Y �ffg Month Day Year <br /> Uj <br /> LL 0 16- Trans rler 2 Acknowledgement of Receipt of Materials <br /> D RPrinled/T d Name <br /> E Printed/Typed Signature Month Day Year <br /> 8 <br /> Taj ]9. Discrepa cy indication Space <br /> F �,y4e A,f4I I`C*- PUr i-Y <br /> C 1'(= <br /> t-0r1 7Gil41ifOt111UYIyiiI <br /> Li 4 .ULol, l r k)1t _Wei ZI,0,Lc,?-5 "Xi,20. Facili ner or O erator Certification of recei 4,f hazardous materials covered b i manifest except as noted in Item 19. <br /> T Pr Me yped Name Signat Month Day Year <br /> 3 <br /> DO NOT WRITE BELOW THIS LINE. { z z- ', 0 �- <br /> DTSC 8022A(1/99) While. TSDF SFNDS THIS COPY IQ DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 To: P 0- Box 3000, Sacramento, CA 95812 <br />