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State of California—Heatth and Welfare Agency Department of Health Services <br /> F,nrm Apyrdved OMS No.2050--0039'(Expime 9-3088) Toxic Subatencee Control Divieion <br /> Please Print or Form designed for too on elite 0swriffsr). Sacramento,California <br /> .n <br /> UNIFORM HAZARDOUS I1. Generator's US EPA ID No. Manifest 2. Pape 1 Information in the shaded areas <br /> Do <br /> WASTE MANIFEST C A D 9 8 1 4 5 9 9 4 0161 te °i1 <br /> is not required by Federal low. <br /> 3. Generstnr's Name and Mailing Address A. State�j }d�je�,ro omen umber <br /> SANTA FE RAILWAY CO. U( ULr <br /> DAMOND h E. WORTH SN STREET $.-State Generator's to <br /> 4. Genarat�N(CA )95205 (213)267-543# ' ' ' ' ' '" H JY IR IQ 1316 - 10 !0 !713 <br /> O 5. Transporter/Company Name 6. US EPA ID Number C. State Tranaporter's ID YO <br /> n <br /> -h �� Tnnsporter'e Phone <br /> n <br /> 7. Transporter C mpany Name 8. US EPA tD Number E. fiesta Tranepotla4 a ID <br /> m <br /> 9 / y ! F. TrensPorter'e Phon <br /> m <br /> : 8. Designated Facility Name and Site Address 10. US EPA ID Number G�pState Facility's 11) <br /> GIBSON OIL A REFINING CO INC. <br /> a C"MRICAL DRIVE H. Facility's Phone <br /> L) <br /> BARERSFIELD CA 93308 AD C9 8 0 8 B 3'1 7.- X803)327-0413 <br /> Z 12. Containers 13. Total 14. I. <br /> -O i/. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit $Waste No. <br /> No. I Type Wt/Vo <br /> v a. WASTE OIL SOLUTION, N.O.S. ;State 2 <br /> 21 <br /> E COTIBDSTIBLE LIQIIID, NA '�7�70y b 'EPA/OtNE <br /> 3 E b. -State <br /> _N R <br /> A. FPAi Other <br /> m T <br /> pH c . State <br /> 0 <br /> m EPA/Other <br /> ¢ d. State <br /> F <br /> Z EPA/Other <br /> L) <br /> l"IN J. Additional Descriptions for Materials Listed Above K. Handling Codeetor Wastes Listed Above <br /> in 0 OIL O 1 <br /> o <br /> C7)w <br /> ¢ <br /> WATER. i � C. d <br /> CV a <br /> C)z <br /> O 15. Special Handling Instructions and Additional Information -. <br /> �H <br /> Cbz GLOVES SAFETY GLASSES <br /> J <br /> 18. <br /> U 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, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> International and national government regulations. , <br /> w 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 <br /> ,dalermined.to,be cgomicaily cticable and that I have selected thepracticable mot it of treatment. Storage, or disposal %"Imily available to <br /> 0 me which minimized the present. future threat io humambealth and the environrine OR,,if I am asmall quantity generator, 1Nlave'made a good <br /> p>- faith effort to minimize my waste generation and select'theaeat waste management method that is available to me and that I can afford. <br /> W Print /Typed NemrSignet Month Day Year <br /> W ,�.� �� <br /> g T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W R <br /> A Print sped Name /' a ore M nth Day Year <br /> Z N ,F/11/�/s <br /> S <br /> LL <br /> O PO 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> WR <br /> =T Printed/Typed Name Signature - Month Day Year <br /> U ,E <br /> _ '191, p dipetien a°e �=7q 5 _ _ <br /> a. F r <br /> A ^ <br /> C <br /> I A,n � � <br /> L <br /> t 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Nem 19. <br /> T Printed/Typed NameSignature Month Day Year <br /> Y <br /> DHS 8022 A(1/e7) Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS INSTRUCTIONS ON THE BACK <br /> (Rev..9.86) 29 <br /> EPAPrevious editions are obsolete. <br /> !1 <br />