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State of Colifomio—Health and Welfare Agency Department of Health Services See Instructions on back Of ge 6. Toxic Substances Contra Program Please Print or ype. Form despised for use on elite(11-p wrifer). Socramento,Califom o UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest Document No. 2.Page 1 nformation in the shaded areas WASTE MANIFEST C 1 A 1 L I 0 10 10 10 10 19 18 15 18 0 1 O 0 1 O I 3 a 1 °not`squired by sale a k7w. ,],^ rcrtors Name and Mating Address ,A.State Montest Document Numoertnt�,� �^ 77377' P. 0. Box 5811, San Mateo, CA 94402 a state Generators. 4.Generator Phone(4 15 ) 571-2424/571-2428 t c t`3 1 6 1 _1 01 1 f r Ie f I 5.Transporter ICompdnyNome 6.US EPA ID Number C.State Trranporters0 200540 H & H Ship Service Company Irlin 14 17 17 11 11 19 IR D. Transporter'sPhone (1415)':543-4:535 7.Transporter 2 Company Nome a.US EPA ID Number E.Store.Traruportefs ID I I I I I I I I I F::Transporter's.Phons uQi 0.Denoted Facility Name and Site Address 10.US EPA ID Number G State iaceys tDI: H I H Ship Service Company CI:AEDt.Q10E4f<717i1E1t5E$ CN 220 ChinaBasin Street H FoCldy:Phone m San Francisco, CA 94107 r I I 11 11 , I R41 12 Containers 11 Total IA UM 11.US DOT Description(including Proper Shipping Name.Hazard Clam,and ID Number) No. Tvpe Quantity Wt/Vol G Waste tYUmbet w a ;StLfri .. ; G RESIDUE GASOLINE TANK (`¢ E NON-RCRA HAZARDOUS WASTE SOLID 0 10 11 T 1? 0 16 10 0 0 a �c N � Stare m R EMPTY GASOLINE TANK Q A NON-RCRA HAZARDOUS WASTE SOLID 0 ,0 1 Ti? 01410 ;0 A P ': �U t G stets Lr)= o R EPa/Oft>et 1 I I I I I 1 N d Stdtb O m Q N I I I I I Q oJ AddrtfondDsscnptksnsforMatenoaCstgd::Above K.Handling Codes for.Wanes Listed Above as EPfPT'l f�t�JEQ .:Ic,n and 4r.t}» E3 g13, r ' �.ns 3.as a :q antaxnzng gasa �nect hanks izferte �t ice 4 0� Z � Fr anjlw U 15.Special Handling IrMrucibrs and Additional Information I N JOB #9660 JOB SITE: ARCO AM/PM, 42076 Z 24 Hr. Emergency Contact: H & H #(415) 543-4835 800 E. Kettleman Lane w APPROPRIATE PROTECTIVE CLOTHING AND RESPIRATOR. Lodi, California c J Q 16. GENERATORS CERTIRCATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping ranle and are ckssuried, ZO pocked,marked,and labeled,and are in all respects h proper condition for transport by highway according according to applicable internationaland natkxsd regulations. regulatkxs Q If 1 am a large quantify 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 Z economically, h practicable and that I have selected the procticable method of treatment,storage.or disposal currently available to me which minimizes e present and future w threat to hu rnan health and the environment;OR,lt I am a smog quantify generator.I have mode a good faith effort to minimae rrty waste generation and seiect the best waste = management method that a available to me and that 1 can afford QPrinted/Typed Name Signature / Month Day Year U - L ( li�� ' 1 1 / 1 I 1 12 10 19 1 ti T 17.Transporter 1 A knowiedgement of Recerot of Materials ry U R Printed/Typed Name Signature Month Day year y A Z s RG JANES R. Nn -�N w S 1 12 1 0 1 9 I T ro 18.Transporter 2 AcknovAedgement of Receipt of Matenals R Printed/Typed Name nature Month Day Year Lu T 0 R 11 1 I w N 19.Discrepancy Indreatan Space U F z A — C I 20.Faclity Owner or operator Certification ceiot of hazardous materials covered by this mandest exc 'em 19. T Pmted/TYPedName Signature Month 07y Year V I NOT WRITE BELOW THIS UNE. DHS 8022A(12/90) _ EPA 8700-22 -