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e1aruornaa—CPWfaememalmore[nenAgency <br /> Form Approved OMB No.2050-0039(Expires 9-30-94) See Instructions an back of page 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for uie an elite(12-pit ewrifer, Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest Documk . 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST C1 A] DI P41PJ41 3121714118101 3 1 1 10 7 16 of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A 5fatd Matefes#DacvmeM Numbe � <br /> TERESI TRUCKINGLn <br /> tit <br /> P. o. Box <br /> r�1270, Lodi , CA 95241-1270 lieneratae�If] ' . <br /> sC%n 4. Generator's Phone (20 3t,1�^��! ca�r ;`� f',a-�#' r '' <br /> COi, E <br /> a 5. Transporter 1 Company Name 6. US EPA ID Number �faf$'tl�/nesPfnt}IG <br /> Oaa? MOR CAL OIL r <br /> r V k <br /> c n D 9 it 2 4 1 7 2 5 5 D "tfdit}pBr.-,, <br /> 7. Transporter 2 Company Name 8. US EPA ID Number Stgf6,Tre�istpoeftiTi iD ; <br /> F trdts�dtfn)'�Pbdti a `a s <br /> Q •` s � <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G 4f$idfd, tieirdy'},1D J'i`! � <br /> 0 REFINERIES SERVICE <br /> 13331 fI. Flwy 33 r Tyrs Ph <br /> .� Pattioremn, c C n U 0 3 1 G C 7 2 3 <br /> 12. Containers 13. Total 14� unit <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) P <br /> Z o No. Type Quantity Wt/Vol <br /> j� NON-RCRA HAZARDOUS WASTE LIQUID S'a <br /> � 3 c (WATER & OIL) �, u�_. ur,;`_�•� <br /> C4 E 9A 1 T T OTO 1 5 0 r, Er�� <br /> ccoN b• <br /> Do > <br /> N R PPA�Utlal;i• <br /> d A <br /> C. <br /> m 0 <br /> a R ~.fPA,Ian! <br /> LU «'-•, b <br /> F- d mR, , <br /> Z <br /> U <br /> LU EPdjiiTtr,_ <br /> Z t `: Adlinq Cam fol wyasie�`4 fated A664Y <br /> k PS <br /> W -.k a tc <br /> v „ger'^➢r �� <br /> Q 15. Special Handling Instructions and Additional Information <br /> a APPROPRIATE PROTECTIVE CLOTHING <br /> Z "EMERGENCY C014TACT: (209) 667-6692" <br /> z SEE E.R.G. PAGE 31 <br /> t- <br /> `Jr I& GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> 1, <br /> .�.iIf I am a large quantity generator, 1 certify that 1 have a program in place to reduce the volvme 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, air disposal currently available to me which minimizes the present and future <br /> Nthreat 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 Martin <br /> that is available to me and that I corn afford. <br /> Q Printed/Typed Name f art n Thorpe agent �A4x Signature �,'; r�sMonth Day Year <br /> for Teres) Truckino 7j1_�.: C r `;_,%!`f L.-p- O Z 7 9 4 <br /> Z T 17. Transporter I Acknowledgement of Receipt of Materials <br /> 4U <br /> A Printed/Typed Name Signature f .- Month bay Year <br /> S Joe Puett 0 14 2 1 7 9 14 <br /> Uj r <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> I Printed/Typed Name Signature Month Day Year <br /> LL E <br /> O it <br /> LU 19. D>iscrepanc4 Indication Space <br /> N <br /> V A <br /> Z_ C <br /> I <br /> L <br /> 1 20. facilityOwner or Operator Certification of recei t of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (7/92) <br /> EPA 8700-22 'r.,. :. r TITI! 51()e PFTAIIIS <br />