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1 ' p r_d <br /> —1'"t o Ilforn/la—���--yyllle/a�rh and welfare Agency Depa/tmant of Healtn Services <br /> _ --/7 Substances Control Division <br /> 64& Sacramento,California <br /> Please print or type. (Form designed for use on elite(12 pitch)typewriter.) <br /> UNIFORM HAZARDOUS enerators o. and est age normation in the shaded areas <br /> CAC 0000 15404 D ment No. of is not required by Federal <br /> WASTE MANIFEST law. <br /> enerEscaloneUnifiednSchool District r3"�r76 ment Number <br /> F 1 19 <br /> 15c201nYosemite Avenue tate Generator's 1 <br /> 4. GenerEY6�£PIS" Fa 95329 209-838-3591 SRNHR 28-818980 <br /> . ranspoteer ompany Name 6. US EPA ID Number C.State Transporter's ID /) <br /> Too's Barrel Co. CAT .00.06.1121.0 . . ransporter a Phone 4 Sol 2_ <br /> 7. Transporter 2 Company Name US EPA ID Number t.5tate Transporter's ID <br /> F. ransporter's Phone <br /> 9. Designated acility Wame and iia Address 1 U EPA ID Number G.StateFacility's I <br /> H 8 H Shipservice Co g-38-001-78 <br /> 220 China Basin ability: Phone <br /> San Francisco, Ca CAO 004.7711.68 . . . . 415-543-4835 <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(including Proper Shipping Name, Hazard Class, and ID Number Total Unit 1 <br /> a <br /> No. Type Quantitv NAMWaste No. <br /> E a. Empty 500 gal Tank DOI TP 200 <br /> N P 0 004 <br /> E 14 <br /> R <br /> b. Empty 500 gal Tank 001 TP 200 P D 001 <br /> R 14 <br /> r <br /> C. <br /> d. F.lJ.S.D. <br /> J-,,Addltlonal ' 'one for Materialls Usted Above K.Handling Codes for Wastes Listed Above <br /> M Bas Tante 8-t5pt Diesel Tank ^/ <br /> dry, icor 10 lose dry ice <br /> 15.Special Handling Instructions and Additional Information <br /> 16.GENIERATOR'S A 1 :I herebydeclarethatthe contentsof this consignmentsre fully and accuratelydescribed <br /> above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for <br /> transport by highway according to appiicabie international and national governmental regulations. <br /> Printed/Typed Date <br /> yped Name S elute Month Day Year <br /> Mark Hoover ! v1 7a . G1xq I Y <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> N Printed/Typed Name _Signature ^ �' Month Day Year <br /> C Howard Eslick l" &4 <br /> n 18.Transporter 2 Acknowledgement or Receipt of Materials Date <br /> T Printed/Typed Name Signature _ - r i r Month Day Year <br /> 19.Discrepancy Indication Space P <br /> F <br /> I <br /> T 20.Facility Owner or Operator: Certification of receipt of hazardous materials cover",With t_e#Cela oted in <br /> y Item 9. � <br /> i K C Date <br /> Print Name Signature Month Day Year <br /> DPA 8r0o22)i84j Yellow: TSDF SENDS T COPY TO GENERATOR WITHIN 30 DAY 8. 606.41 <br />