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State of Colifornio--Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-3694) See Instructions on back ge 6. Department of Tox;c Substances Control <br /> Please print or type. Form designed/or,use an else(12-pitch ewri,er. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator s US EPA ID No. Manliest Document No. 2. Page 1 Information in Me shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST C JA I D ') i'. .i 13 IE I I3 6 18 4 1 3 1 9 of <br /> 3. Generator's Name and Mailing Address r,. p O A. State Manifest Document Number <br /> 17100 s A1..r : 93 <br /> set 0 BOK 279 643925 <br /> P <br /> LATHROP CA 95330 e. smene <br /> State <br /> 4. Generator's Phone I, ) ' � <br /> 5. Transporter 1 Company Name 6. US EPA 10 Number C, Stone Trensporter's ID <br /> OD D. Transporier's Phone <br /> VAN WATERS & ROGERS INC CAD 0 4 i. 6 5 6 8 5 1 916-371-7600 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> Q <br /> U VAN WATERS & ROGERS INC C A D 10 11 10 19 1 1-5 15 17 -; F. Transporters Phone 408-435-8700 <br /> LO Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> N ZW CHLi'IICAL WASTE MANAGEMENT, INC. 10161614161/ 1/ 1 1 <br /> CF)O 35251 OLD SKYLINE ROAD H. Faa ho e <br /> MJ 41.SAVI L <br /> V - 12. Conminei-, 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) <br /> • Z No. Type Ouantiy Wt/Vol I. Waste Number <br /> MX a NON—RCRA HAZARDOUS ',TASTE, SOLID State <br /> 1- G (UREA) 181 <br /> 013 EPA/Other <br /> r E F <br /> N Is. State <br /> t as E <br /> N R EPA/Other <br /> e V <br /> T Stare <br /> t O <br /> R EPA/Other <br /> W <br /> w <br /> Z d. State <br /> Z <br /> w <br /> V EPA/Other <br /> w <br /> Z J.Additional Descriptions for MaledalsUsfed Above K. Handling Codes for Wastes listed Above <br /> ' O 11A. UREA NITRATE p. b. <br /> W <br /> m <br /> d <br /> f Z <br /> � Q 15 Special Handing Insirucfons and AddYonal Inlormaio hP.A : .S" �L L. "if 'L`r;CTI V(; Li A�� t,'Hh.a aA�`-JL_T.Yv(;. <br /> a EHEKGENCY CONTACT: CHEHTREO: 1-800-4_4 +3010. CALLER MUST 1DENTIF`i VAr! WATERS ti <br /> ROGERS AS SHIPPER. <br /> i Z 11A. AJ5359—KHF <br /> = ACCOUNT #680-680-6014205 <br /> � 16. GENERATOR'S CERTIFICATION: I hereby declare that the content of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> U <br /> V <br /> 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 /> 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 /> r d threat to human health and the environment; OR, it I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available no me and than I can afford. <br /> 0 Printed/Typed Name Signature _ MonthDay Year <br /> { � ' 0 -207 17 15 <br /> Zx 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w A Printed/Typed Name Signatureq Month Day Year <br /> (7 n G ✓ <br /> w F <br /> 0 18. Trans orter 2 Acknowled emenf IST Recei 1 0l Materials <br /> w T Printed/Typed Nome Signature Month Day Year <br /> LL E <br /> O R <br /> Cr s 19. Discrepancy Indication Space <br /> 4 r N F <br /> U A <br /> Z C <br /> t — k <br /> 20. Facility Owner or O eralor 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 /> 1 r <br /> f DO NOT WRITE BELOW THIS LINE. <br /> f <br /> f iOR SENDS iH15 COPY TO DISC WITHIN 30 DAYS. <br /> I DTSC 8022A (9/93) -.0. Sax 400, Sacramento, CA 95812-0400 <br /> I EPA 87OD-22 <br />