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- Ali- <br /> Slate of Celifornie--Health and Welfare Agency ir Department of Health Services <br /> Form Approved OMB No. 2050-0039(Expires 93088) Toxic Subslancee.Control Division <br /> Please riot or type. Form designed for use on elite(12-pitch typewriter), Sacramento,Coliforms <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No, Manifest 2. Paget Information in the shaded arses <br /> WASTE MANIFEST C DI10111415 g 4 4, _ Dp(meat No. et 1 is not required by Federal law. <br /> S Generator's Name and Mailing Address A. State Manifest Document Number - <br /> SAWLAY n RAIL,WY CO. B. state Gen � <br /> {; 1 <br /> WIDN"D �• E. NORTH S'Y�HT'.T Generator's 10 <br /> o. Genef � en CL 95205 o n * . <br /> ( > 213•-z�J?—•S�ASt. IY '� 13 6 OI � R, 4 I <br /> 5. Transporter 1 Company Name 6, US EPA ID Number C. ffielo Trenspodsr's ID w,,,�, '� <br /> V-11ICRSOIT INC. C1 AI DI 0 01914 Fi 1613 19 12 D, Tre tumniter'sPH... 415-2";-1'93 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G State Fill <br /> CIBSON OIL 5 RUINING CO INC. <br /> COW".'L7RICAL DRIVE. y - � H. Facility's Phone <br /> BXCEFSFeE111 CA 93308 VD1 ,91 810,181's 3 1 7 17 805-327-0413 <br /> 12, Containers 13. Total 14, 1. <br /> 11. US DOT Description(Including Proper Shipping Na",Hi zard Class.and ID Number) .Quantity Unil Waste No. <br /> No, Type W,/V <br /> a. $fat9 <br /> C <br /> WASM? OIL SOLUTION 17.0.3. 2 T I <br /> ..�+'Y EPA/Other <br /> N COMBUSTIELE LI UIDS . BA 1270 0 0 1 T T G NONk: <br /> E b. , - Stele <br /> R <br /> i <br /> A EPA/Other I <br /> T <br /> R <br /> a state <br /> EPA/Other <br /> d. State <br /> EPA/Other <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> ff .� <br /> . �.-v a. b. <br /> OIL /70 2 <br /> /? //_ 1 0 ' <br /> HATER 2 Q 2 <br /> t ,J <br /> p <br /> 15. Special Handling Instructions and Additional information <br /> CLOVES, SAFETY GLASSES <br /> 6. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked;antl labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international and national government regulations. <br /> If I em 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 <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environmemt; OR, if I am a small quantity generator, 1 have made a good <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford <br /> Prince yped Na a 6ignalure ' Month Day Year <br /> / %o <br /> )l� <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Print ed N/me / SWnalure Month Day Year <br /> Ns <br /> P <br /> O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Primed/Typed Name Signature Month Day Year <br /> E <br /> T <br /> 19 Dunincre.pailicy Indy tion Space, }s,s <br /> C <br /> ( <br /> L <br /> 1 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, <br /> Printed/Typed Name Signature Month Day Year <br /> LI 1� 1=>S 1 �1�13101 <br /> DHS 8022 A(1/g7) <br /> EPA 8700-22 Yellow: TSDF SENDS THIS COPY TO GENERATOR (THIN 30 DkA INSTRUCTIONS ON THE BACK <br /> (Rev.8-08) Previous editions are obsolete. <br />