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of Celilornie—Health and Welfare Agency <br /> Approved OMB No.2050-0039(Expires 9-3 Department of Health Services <br /> Toxic Substances Control Division <br /> se print or type. (Form designed for use one -pitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID Na. Manifest 2. Page t <br /> ocument No Information in the shaded.1... <br /> WASTE MANIFEST of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 89802496 <br /> ¢fQ` 41e' 2/y/25CN— B. State Generator's ID <br /> 4. Generator's Phone( _ <br /> 6. Transporter 1 Company Na e. US EPA ID Number C. State Transporter's ID <br /> Ref ine_ies Serivice ( A D (! 1 !J �j 2 6 D. Transponer's Phone <br /> N6742 <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter'.ID <br /> 0 <br /> O 1 1 1 1 1 1 1 1 1 1 1 1 F. Transporter's Phone <br /> m <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> DQ Refineries Serivice <br /> A0 13331 N. NWY. 33 H. Facility'.Phone <br /> 7Z Patterson CA. 95363 -, <br /> uit¢ - <br /> v0 12. Containers 13. Total 14. I. <br /> w 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouantity Unit Waste No. <br /> No. Type Wt/vol <br /> )per a. AM )J A(Z R R I.V>9 T7 e /C f U /� <br /> n z state <br /> G <br /> 0 r N <br /> EPA/0the <br /> 3 E It. <br /> iv R <br /> A Ly <br /> m T L EPA/Other <br /> N O <br /> a R c. <br /> S State <br /> V 2 G 7990 EPA/Other <br /> w d ENVIRONMENTAL HEALTH state <br /> W <br /> PERMIT/SERVICES <br /> 0 EPA/Other <br /> w <br /> Z J. Additional Descriptions for Materials Listed Aqbove - K. Handling Code.for Wastes Listed Above <br /> d. <br /> J <br /> ¢ <br /> Z <br /> O <br /> 15. Special Handling Instructions and Additional Information <br /> Z Wear Gloves Goggles & And Protective Clothing <br /> INCASE OF EMERGENCY CALL (209) 892-6742 OR (209) 1-800-674-4444 <br /> J <br /> J <br /> tl 18. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J 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 /> V) <br /> ¢ If 1 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 <br /> 0 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 /> y present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a flood faith effort to minimize my waste <br /> 0 generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> w Printed/Typed Name Signatur <br /> ¢ Month Day Year <br /> W R 17. Transporter 1 Acknowledgement of Receipt o ateriala <br /> < A Print d Name <br /> N Signet' Month Day Year <br /> LL 3 <br /> O p <br /> W O 18. aporter 2 Acknowle gement of Receipt of ateriala <br /> m <br /> ¢ R Printed/Typed Name Signature <br /> 0 E Month Day, Year <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Name Signature <br /> Month Day Year <br /> DHS 8022 A(1/88) <br /> EPA 8700-22 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 />