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State of California--Health and Welfare Agency <br /> Form Approved OMB No.2050--0039(Expires 930-91) • Department of Health Services <br /> Please tint or e. Toxic Substances Control Division <br /> P type. (Form designed for use on elite( ch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 <br /> WASTE MANIFEST Document No. Information in the shaded areas <br /> of is not required by Federal law. <br /> . <br /> =Generator's Name and Mailing Address A. State Manifest Dc N m�er <br /> Delta Air Strip 8 ��e227 <br /> 15971 S. Tracy Blvd„ Tracy, CA 95376 e. state Generatgr'a ID <br /> 4. Generator's Phone(2091.948-9345 (operator) <br /> nS. Transporter 1 Company Name e. US EPA ID Number C. Stets TraneDorler's ID <br /> Refineries Service D. Trenaporter'sPhone N <br /> T 7. Transporter 2 Company Neme e. S PA 10 Number E. State Transporter's <br /> O <br /> 00 F. I ransponer'e Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Refineries Service <br /> N013331 N, Hwy, 33, Patterson, CA 95363 H. Facility's Phone <br /> a <br /> CJ ¢ 3 1 6 6 7 2 8 209-892-6742 <br /> W O 12. Containers 13. Total 14. I. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> r a'Hazardous <br /> G Waste Liquid NOS ORM-E NA 9189 State <br /> = <br /> Co E EPA/Other <br /> 23 <br /> 3 N <br /> E b. <br /> v R State <br /> A ✓ <br /> Op <br /> O V~ EPA/Other <br /> IT 8 R MAY 2 4 1990. Nall State <br /> EPA/Other <br /> T11 <br /> X <br /> d' State <br /> Z <br /> W <br /> U EPA/Other <br /> w <br /> N J. Additional Descriptions for Materials Listed Above <br /> Z Handling Codes for Wastes Listed Above <br /> oa.a. 01 D. <br /> rn <br /> rinsate c. d. <br /> a <br /> 0 <br /> Q 15. Special Handling Instructions and Additional Information <br /> Z <br /> J <br /> U 18. <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable International and <br /> d national government regulations. <br /> W <br /> 2 If I am a large quantity generator,1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> p to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,if I am a small quantity generator.I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> Printed <br /> /Typed Name 1 Signature, �- / Month Da�y'1 Year <br /> cc <br /> WT 17. Transporter 1 Acknowledgement of Receipt of Materi <br /> Z R <br /> a N Printed/Typed Name gnature Month Day Year <br /> p P S le. <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> N <br /> a R Printed/Typed Name <br /> O E store Month Day Year <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Rem 19. <br /> T <br /> y Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A /88) <br /> EPA 8700-222 Do Not Write Below This Line <br /> (Rev.9-88)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />