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Ssc:Inateustln�a on Rack of rage 6 ToxicSubstancesControl Division <br /> Stute o'Cellfornla—Health and Welfare Agency Sacramento,California <br /> Farm Approved OMD No.2050--0039(Expires 930.91 anFir of rage <br /> Plows print e h pe. (Form designed for use on elite. h typewriter). Manifes rage 1 information in the shaded areas <br /> UNIFORM HAZARDOUS + nerator's US EPA ID No. °oppmppt <br /> of 1 Is not required by Federal law. <br /> WASTE MANIFEST CAC 0 0 0 8 9 0 4 1 6 1O A Tele t"an{fe Document Number <br /> 3. Generator's Name and Melling Address - L 77 8811297U 8112970 <br /> THE PORT OF STOCKTON B. State Generator's ID <br /> 2201 W. -Washington St. , Road B, Stockton, CA <br /> 4. Generator's Phone(209) 946-0246. I <br /> g, US EPA ID Number C. State Transporter's ID <br /> u, 5. Transporter+ Company Name D. Trensporter'e Phone <br /> NOR CAL OIL CAD982417255 <br /> d, 8, US EPA ID Number E. State Tranaporter's ID <br /> Ln 7. Transporter 2 Company Name F. Trenaporter's Phone <br /> m <br /> C? 9. Designated Facility Nem.end_Sit.Address 10. US EPA ID Number G. State Facility's ID L <br /> REFINERIES SERVICEFacility's <br /> C A D on 81 31_ 1 °6� 61 71 2L8 <br /> --1 - H. FacI1nY s Phone ^ <br /> L) 13331 NORTH -HWY. 33 (800) 874-4444 <br /> G7 z PAT RSON CA 95363 CAD 0 8 3 1 6 6 7 2 8 <br /> 12. Containers 13. Total 14. i. <br /> N¢ - OuantitY Unil Waste No. <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) No. Type Wt/Vol <br /> c_•{J state. 223 <br /> Q a. <br /> CO z o HAZARDOUS WASTE LIQUID N.O.S. G EPA/Oher� <br /> O O 1 T T <br /> F E ORM-E NA-9189 p <br /> stgte <br /> t N <br /> E b. <br /> N R EPA/Other <br /> A <br /> mT <br /> N O Stale <br /> V R c. <br /> 0 EPA/Other <br /> 0 <br /> m <br /> late <br /> F_ d EPA/Other <br /> Z <br /> tu <br /> WK. Handling Codas for Wastes Listed Above <br /> N J. Addition Ml Descriptions for Meiarials Listed Above a Ii <br /> Z <br /> O <br /> W TANK BOTTOM WASTE d. <br /> ¢ RINSATE <br /> J <br /> Z <br /> Z <br /> O <br /> Q15. Special Hantlling Instructions and Atlditionel Information <br /> Z SEE E.R.G. 31 <br /> Ul "EMERGENCY CONTACT: 800--332-871011 <br /> APPROPRIATE PROTECTIVE CLOTHING <br /> J <br /> 1g. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and ere classified,packed,marked,and labeled,and are In all respects In proper condition for transport by highway according to applicable international and <br /> W 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 toxics ydisposalofwaste <br /> generatedrrently to the deme e I have determined <br /> the <br /> O to be economically practicable and that I have selected the nt;OR,it I mthod of 8 smalllquantity generator,I have made a good faith effort to minimize my waste <br /> present and future threat to human health end the environment;OR, <br /> U generation and select the beat waste mertagement method that Is available to me and that I can afford. Month Day Year <br /> IJU Printed/Typed Name Pub 4Te-01 Signaiuje <br /> W <br /> T 17. Transporter 1 Acknowle gement of Receipt Materials - Month Day Year <br /> R Signature <br /> ¢ p Printed/Typed Name )® � <br /> N U <br /> 0 S <br /> P 18. Transporter 2 Acknowledgement of Receipt of Materiels <br /> W O Month OMY year <br /> V 7 Printed/Typed Name n re <br /> E <br /> Z <br /> . 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I _ 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manilas[except as noted In Item 19. Month Day Year <br /> yPrinted/Typed Name Signator Q <br /> DHS aoz2 A(vee) Do Not Write Below This Line White: TSDF SE THIS COPY TO DOHS WITHIN 30 DAYS <br /> EPA 87DO-22 ' _ To: F.G. Box 30W, Sacramento, CA 95812 <br /> (Rev.6-88)Previous editions are bbs'Glate. <br />