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State of Colifornio—Environmental Protection Agency <br /> Form App gved OMB No.2050-0039(Expires 9-7096) See Instructions on backage 6. Department of Toxic Substances Control <br /> �wse print or type. Form designed for use on elite(12pi pewrger. Socromesam,California <br /> Is UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information In the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST CAC0007642489® 1 50 2 a+ 1 <br /> 3. Generator's Name and Mailing Address A. Stole Manifest Document Number' <br /> ROBERT G. HOWEN 96591502 <br /> Lf) 1008 Vienna Dr. , Lodi , CA 95242 B. State Generator's lD <br /> d. Generator's Phone 12091 333-8740 <br /> $ 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID <br /> so <br /> NOR CAL OIL CI A 91 q 21 41 11 71 21 5 1D. Transporter's Phone 2D9 667-6692 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> (V U <br /> OF. Transporter's Phone <br /> Q <br /> L,(') Z 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> W AMERICLEAN, INC. O q <br /> M ; 2570 Almond Dr. H. Facility's Phone <br /> L0 el: Silver Springs, NV 89429 1 NJ VI DI 91 a 2 (800) 471-2105 <br /> LQ 12. Containers 13. Total M. Unit <br /> y Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. 1 e Quant Wl/9ol I. Winds Number <br /> NON-RCRA HAZARDOUS WASTE LIQUID State 223 <br /> 3 c (WATER & OIL) a�5 <br /> o f 0 0 1 <br /> TIT <br /> III G EPA/Other <br /> Toro N le. State <br /> y' E <br /> V R EPA/Other <br /> 6 A <br /> g0g re <br /> T c. State <br /> O <br /> K R EPA/Other <br /> HZ <br /> Z d. Sae <br /> V <br /> w EPA/Ceher <br /> Z <br /> Z J. Additional Descriptions for Materials Listed Above - K. Handling Codes for Wastes Listed Above <br /> TANK BOTTOM WASTE b. <br /> RINSATE 0 <br /> d. <br /> Z <br /> 15. Special Handling Instructions and Additional Information <br /> a APPROPRIATE PROTECTIVE CLOTHING site: 251 Ticknor Ct. , Lodi , CA <br /> Z "EMERGENCY CONTACT: (209) 667-6692" <br /> SEE E.R.G. PAGE 31 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare thus the contents of this consignment are fully and accurately described above by proper shipping name and are c1coOrd, <br /> Upacked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <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 1 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 Bre environment;OR, if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best <br /> sY waste management method that is available to me and that I can afford. <br /> O Printed/Typed Name Richard Thorpe agent for Signatc Month Day Year <br /> U Robert G. Howen \\ 1 1 0 1 1 91 6 <br /> Z T 17. Transporter 1 Acknowledgement of Receipt ofMaterials <br /> X Printed/Typed Name RjXKXXNXl♦F1NXNNX ��s SigaaNre Month Day Year <br /> w ; R&6S�k$XNl(XN�tW�13 / 1 1 0 1 9 6 <br /> W0 I8. Tran orter 2 Acknowled ement o Receipt of Materials Jr <br /> st- i Printe ped Nam ignalure .. Month Day Year <br /> O i <br /> sn 19. Discrepancy Indication Space <br /> U A <br /> Z C <br /> I <br /> L <br /> I 20. Fsjft Owner or OSerator Certification of receipt of hazardous materials anifest except as noted in Item 19. <br /> T rated/Typ d Name Si abre ( 1 McMh Day Year <br /> DO NOT WRITE FLOW THIS LINE. <br /> W6IIr: ISItF SENDS 11115 COPY 10 DISC WITHIN 30 DAYS, <br /> DTSC 8022A )1/95) To: P.O. Box 3000, Sncrnmrnto, CA 95812 <br /> EPA 8700--22 <br />