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State of C,;wornia---Health and Welfare Agency See Instructions on Back of Page 6 Department of Health Services
<br /> Fbrm Approved OMS No.2050-0039(Expires 9-30-91) /'�+, Toxic Substances Control Division
<br /> * and runt of Page 7 Sacramento,California
<br /> Please print or type. Form designed for use on elft*(12-A7 writer). .!
<br /> UNIFORM HAZARDOUS t. tae ,.- US EPA ID No. Manifest I Informatlon In the-shaded areas
<br /> WASTE MANIFEST CAC000571 1280o0OI I 1 I�
<br /> Of la not required by Federal law.
<br /> 3. Generator's Name and Mailing Address CLARK WELL 'A.,State Mafliteit�Doqum
<br /> 2024 E. Charter way
<br /> Stockton, Ca. 95203 s stat.GenraratoCa uy�° �� � ,
<br /> '4, Generator's Phone(2091462-7676 C A*
<br /> 5. Transporter I Company Name 8. US EPA ID Number C.:State Tranapartera IDx
<br /> P P CA.*2;463°. �.�_:,W
<br /> aMCON ENERGY ASSOCIATES ICIAID1918121512 6 8 5 7 °" r 209°='463=? 081 :
<br /> u7. Transporter 2 Company Name 8. US EPA 10 Number 8„S1atRT Otfsf*�IG, N��a q„ +
<br /> SOUTBERN T SPORTATION I C I A[ DI 0 101 6191 11 31 2101 6 Transport r'a Phoal` 3148 '6
<br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number 3q ;t FaaUEty s f�f�' , _
<br /> Q THE KIESEL COMPANY �� x
<br /> o #1 Branch St.LQUja, Mo. 63147 1 MI 011131010101 11 11 11 61 O,��V81 4�44
<br /> H. FaatBty's P1ttltte� ,�
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<br /> 12. Containers 13. Total 14. , ,q
<br /> g P Shipping No. Type amity Unit `>
<br /> y 11. US DOT Description(Including Proper Shi kn Name,Hazard Class,and ID Number) yp Oe WtlVol „Fa 4 e
<br /> a TANK RINSEATE SOLUTION, (GASOLINE, DIESEL) , f
<br /> CALIFORNIA ONLY REGULATED.
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<br /> n J AddillonaE Dee flowfor Materials listed'Above e
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<br /> �l7SPECS IC GRAVITY X1.0. 41
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<br /> /b. Special Handling Instructions and Additional Information
<br /> ` MATERIAL PUMPED INTO TANK CAR ACFX 81714 for shipment.
<br /> J 24 Hour emergency response # 1--314-421-0328.'
<br /> 4C 1s.
<br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment re fully and accurately described above by proper shipping name
<br /> and are.classitled,packed,.marked,and labeled,and are in all respects In proper condltic for transport by highway according to applicable international and
<br /> national government regulations.
<br /> If I am a large quantity generator,i certify that I have a program in place to reduce the vok me and toxicity of waste generated to the degree 1 have determined
<br /> to be economically practicable and that I have aelected the practicable method of Ireatme,it,storage,or disposal currently available to me which minimizes the
<br /> present and future 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 ill!
<br /> 1 generation and select the best waste management method that is available to me and the I can afford-
<br />`u PrintedlTyped Name [Signatu e - Month , Day ,Ysai
<br /> 1 G L CLA�
<br /> . R 17. Transporter 1 Acknowledgement of Receipt of Materials
<br /> .A Printed/Typed Name Signet a Month Day Yeari
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<br /> O 18. Trane orter 2 Acknowledgement of Receipt of Materials
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<br /> TPrintedlTyped Name Signature Month Day -Year.
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<br /> 19. Discrepancy indication Space
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<br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manilest except as noted In hem 19.
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<br /> y Printed/Typed Name Signature Month Day ." Year
<br /> Hs 8022 A Do Not Write Below This Line
<br /> PA 8700•-22
<br /> 4ev.8-e9)Previous editions are obsolete. White: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS
<br /> To: P.O. Box 3000, Sacramento, CA 95872
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