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State of California—En%—onmerAol t'roiection,Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-96) See Instructions on backage 6. Department of Toxic Substances Co, <br /> Please print or type. Form designed for use on elite f 1 pewrirer. 0— Sacramento,California <br /> 1. Generators US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address 1'' St a Manifest Docu nt Number <br /> an a 95226551 <br /> Ln SAN .I�:AQUIN D E..,TA CJLIAEG : B. State Generator's ID <br /> 04 151 F' GiFIC Vim. , STOCKTON, CA. 95'207 <br /> LO d. nerafars one ( r <br /> W1 C15. <br /> 0 5, Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID <br /> 0@ <br /> r D. Transporter's Phone <br /> J <br /> J <br /> < 9m Company 7. Transporter 2 Com an Name B. US EPA ID Number E, State Twnsporfer's 1 <br /> U <br /> F. Transporters Phone <br /> a <br /> Z 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 0 FRG =ATTERS(JN, INC, ' <br /> I� <br /> J <br /> 1333! iV V. hl- J. 33 <br /> H. Foci 's one <br /> Q t r� f' ? n 7 ° `00-971-44 A <br /> ,-� U �'AT L�l�','(tI4 � - � ' <br /> 11. US DOT Description(including Proper Shipping Name,.Hazard Class,and ID Number N Containers 13, Total 14, Vol <br /> P �� 9 P PP� 9 } No. T Quantity Wt/Vol I. Waste Number <br /> 2 <br /> State <br /> in 3� 0 L, �,,'JJ`s RCRA l,AZARi; ( �, 4A }E 1.1;LJID EPA/Othfx" <br /> . <br /> co N b. State <br /> 4 E _ <br /> EPA/Other <br /> o A r— <br /> T c. State <br /> 0 <br /> R EPA/Other <br /> LU <br /> Z d. State <br /> w <br /> V <br /> w EPA/Other <br /> V) <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wostes Listed Above <br /> a 1 a. 1 b. <br /> c!7 <br /> w <br /> � L <br /> J c. d. <br /> Q <br /> Z <br /> Q15. Special Handling Instructions and Additional Information <br /> z "c'4 dR 04ERGEACk CONTACT. PRC PA:TERSON (800) 574-'4444 <br /> LU W'L HR Fa'IERGENCi; RESPONSE. CHEM Teti,;,, 1NC. (800) 255-33.24 <br /> M NEAR APPROPRIATE PROTECTIVE, CLOTHING AND RESPIRATOR <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations. <br /> V <br /> J If 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 to be <br /> a 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 /> N threat to human health and the environment;OR,if I am a small quantity generator, 1 have made a good faith effort io mir.iriize my waste generation and select the best <br /> d <br /> waste management method that is available to me and that I can afford.. <br /> Printed/Typed Name Sig ature r 0 Month Day Year <br /> Z T 17. Trans rte r 1 Acknowledgement of Recei T of Materials <br /> w _ <br /> N Pri(ted yped Llama } Signatup� s0' }w, Month Day Year <br /> LU S - f- 1 �!!f% <br /> P <br /> O 18. TronspoRer 2—Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> U— E <br /> R <br /> w <br /> to 19. Discrepancy Indication Space <br /> F <br /> U A <br /> Z e <br /> I <br /> L <br /> 1 20. FacilityCtwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item_ 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A (9/94) <br /> EPA 870022 Yellow: GENERATOR RF <br />