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State of Cafifomio—Envfronmemol Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-3494) See Instructions 011 bark �9@ f3. Department of Taxis Substances Control <br /> fff Please print or type. Form designed for use an elite(12plA.1. Sacramento,California <br /> - 1. Generator's 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 Ci AlC1 010111014161812141 8 1 1 120 1 9 of 1 <br /> 3. Generators Name and Mailing Address A. State Mardfest f)acutneM Nv r ''i <br /> Ln � <br /> William Reich �� �.��� <br /> - <br /> l. 57 Corinth Avenue, Lodi , CA 95242 B. State, to <br /> 4. Generators Phone a 2091 334-2354 <br /> 5. Transporter 1 Company flame 6. US EPA ID Number C. Sfatr Traosp."ri iD' <br /> NOR CAL OIL C AD 9 8 2 4 1 1 2 5 5 0 T`°nsp°'"r`�`«" 009 667.66+93 <br /> 7. Transporter 2 Company Name 8. US EPA Il]Number E. Stat"TrcrospaAers ID <br /> V �f,''�ransporter'r'Phar»' .•, <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number `C7.,Stg)s Focllit�c ID <br /> Cn z al <br /> Cr)0 REFINERIES SERVICE - .1 <br /> Q 13331 N. Hwy .33 faciliry'S <br /> 083 7 __ 00 . 8-i Patter-son, CA <br /> 1 4 A: <br /> 00 Z 11. US DOT Description(induding Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> No. Tyu Ovanti Wt/Vol 1.•WasH Numt»r- <br /> 1 N~ a NON-RCRA HAZARDOUS WASTE LIQUID state 221 <br /> icr)3 G (WATER & OIL) 0 0 1 T T[-%".)1',)1/ j r <br /> N E <br /> stele _ <br /> f � b. <br /> N R RPA j0i�r <br /> T C. <br /> 00 O <br /> Z d.Uj <br /> State . <br /> Z I r <br /> V <br /> EPA/, rh <br /> ku <br /> l ZPMat ria -' - K:Handli Gids fog Waw wed Above . : <br /> I ° f� ?l ilk�AfOTTIA WASTEUj <br /> a <br /> [� a .., 1411 Cr• :-Y' Y.,u-. - - •7 c' - d' <br /> f Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> a APPROPRIATE PROTECTIVE CLOTHING <br /> I W "Emergency Contact; (209) 667-•6692" <br /> SEE E.R.G. PAGE 31 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping none and ore classified, <br /> ' J packed,marked,and labeled,and are In oil re m proper condition for transport b highway according to applicable federal,state and international laws. <br /> lQ.l p �n� P Pe P° Y g aY n4 PP <br /> 1 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 /> i 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 /> threat to human health and the environment,OR, if i am o small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> a waste mono ement method that is available to me and that I can afford. <br /> 0 Printed/Typed(Jame Martin Thorpe agent for Signature Month Day Year <br /> } MRORtllllD4N1lE,1 Wm. Reich ]--j <br /> 1 V 'r 17. Transporter I Acknowledgement of Recef l of Materials If i <br /> fl <br /> N Printed/Typed AAcLg2ment <br /> Signature f Month Year <br /> Uj Ce 6i <br /> 0 18. Trans rteof Receipt of Materials <br /> 1L 7 Printed/Typed Name Signature Month Day Year <br /> W 19. Discrepancy Indication Space <br /> to <br /> I 20. Foci!' Owner or Operator Certification oft ei t of hazardous materials covered by this njonifest except as noted in Nem 19. <br /> d Name Sigooture Month Day Year <br /> T Prirrted/Type � .. .. a•, . <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> E <br /> DTSC 8022A (7/92) <br /> EPA 8700--27 h Y�II:«: C:i hJf.NA'Il)k ttPIAIIJS <br />