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t <br />State of vEalifornio—Environmental Protion Agency <br />Form Approved OMB No. 2050-0039 ( Aires 9-30-96) <br />Please print or type. Form desl),ned fo use on elite (12p. .ypewriter, <br />0 <br />In <br />Ln <br />r. <br />04 <br />00 <br />O <br />J <br />Q <br />U <br />U <br />W <br />3 <br />r <br />0 <br />GO <br />00 <br />v <br />N <br />�•a <br />00 <br />ii,r <br />a <br />W <br />r <br />Z <br />W <br />U <br />Q <br />U <br />0- <br />V) N <br />M <br />O <br />W <br />N <br />Q <br />U <br />Z <br />See Instructions on bad page 6. <br />Ir" t j <br />Deportment of Toxic Substances Control <br />Sarrmm�nt� C'nf(e.rnt.. <br />DO NOT WRITE BELOW THIS LINE. <br />O GENERATOR WITHIN 30 DAYS. <br />ardOUS waste for transport out-of-state, <br />EPA 87700-22 <br />DISC 022A (1/95) + this copy and send to DTSC within 30 days.) <br />RDOUS <br />UNIFORMN1,1AA <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTEFEST.-. <br />is not required by Federal law. <br />.L Al01 q1 8121016101 C-1 3141-7 <br />°f <br />3. Generator's Name )nd M iling Address <br />A. State Manifest Document Number <br />AC ART <br />9677.5 . <br />31313 ADART Rn. STOCKTON, CA 9521.5 <br />B. State. Generators ID <br />4. Generator's Phone13,1' <br />( �O .31_-'7r3F)(0 <br />f. <br />5. Transporter I Company Nome 6. US EPA ID Number <br />`C. State�Transporter's ID <br />ALLIED PETROLEUM C AlL101 01011111 ^? <br />1 4 <br />D. Transporter's Phone 209-�y-6-85� <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E, State Transporters ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />ANEnICLERA, TIaC. <br />A <br />2570 AI_MONn DR <br />H. Facility's Phone <br />SILVER SPRIRGS NV '?9439 I t! I V 10 s;1213177-90(h!i 8 <br />4 8 <br />702-5 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />a. CC3MBUSTTRLE KXNX I_To l'31I? ;-10S. n!A 1993 'HITT_ <br />Sime 223 <br />EPA/other <br />E <br />(h!PlST1= PETI'OLE[P; -JL) <br />( <br />T T <br />N <br />b. <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />C. <br />State <br />0 <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other ' <br />1, Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />di/ a 50( "4r <br />-3-21T50( <br />a. �y ( <br />b. <br />¢�fJ� Jit <br />c <br />d. a, <br />15. Special Handling Instructions and Additional Information <br />14EAR } PPOTECTIVc rFV <br />?n r3R PACILTTY 7T12-777-f- <br />T_t2_-%?_1a) <br />140 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br />Packed, marked, and labeled, and are in all respects in proper condition for transport by highway <br />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 I have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or <br />disposal currently available to me which minimizes the present and future <br />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 generation and select the best <br />waste management method that is available to me and that I can afford. <br />Frit /Typed Name <br />Signature t <br />Month Day Year <br />T <br />17. rens orter 1 Acknowled ement of Receipt of Materials <br />R <br />R <br />Printed/Typed Name <br />Signature % <br />Month Day Year <br />N <br />11 kb'ter <br />P <br />0 <br />1 B. Twns orter 2 Acknowled ement of ecei t ials <br />RPrinted/Typed <br />T <br />Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />1 <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Nome <br />Signature <br />Month Day Year <br />Y <br />�l <br />DO NOT WRITE BELOW THIS LINE. <br />O GENERATOR WITHIN 30 DAYS. <br />ardOUS waste for transport out-of-state, <br />EPA 87700-22 <br />DISC 022A (1/95) + this copy and send to DTSC within 30 days.) <br />