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State of California—Health and Welfare Agency Department of Health Services <br /> Fr,rn1 A,aroted OMS No. 2050-0039(Expires 9-30 Toxic Substances Control Division <br /> Please print or type. (Form designed for use on at -pitch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS " Generator's US EPA ID No. Manifest2. Page t Information in the shaded areas <br /> Document No.� of is not required by Federal law. <br /> WASTE MANIFEST . <br /> 3. Generator's Name and Mailing Address - - A. Slate Manifest D cument Number <br /> D_ s . S . .:.1 ,i ,��r , ;z , 8460931 <br /> 690 K. Ci.,a r C;,', <br /> B. State Generator's ID � .. <br /> 4. Generator's Phone( ) <br /> ,o 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID <br /> i lr.�r ,C l !'.:\' j 1.rS•-'.')-l '") ! { t'_ (' l ;-, • } f' % r- D. Transporter's Phone O .1 <br /> N ( l _7 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's Iq 1, <br /> F. Transporter's Phone" <br /> CC <br /> :01 <br /> Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID p <br /> 'tECYCLETIIZ011 OIL, INC . <br /> i �Lai <br /> 13331 N e i t:i} H i j i l ld \' H.IFeci ity's Phone <br /> O 12. Containers 13. Total t4. I. <br /> ty 11. US DOT Description(Including Proper Shipping Name.Hazard Class,and ID Number) Ouantily Unit Waste No. <br /> j No. Type Wt/Vol <br /> a. State <br /> �z G Waste dieSel/Combustible liquid NA 1993 EPA/Other <br /> Co N fl w l 1 ., <br /> 3 E b. State <br /> O <br /> R <br /> A <br />' m T EPA/Other <br /> a O <br /> N <br /> Ir R C. State <br /> 8 <br /> EPA/Other <br /> w d. State <br /> F- <br /> Z <br /> w <br /> U EPA/ <br /> Other <br /> LU <br /> ZJ. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O a. In. <br /> CIL <br /> LLI <br /> AECEIVED c. d. <br /> Z <br /> O <br /> F 15. Special Handling Instructions and Additional Information <br /> RONMENTAL HEATH <br /> PERMIT/SERVICES <br /> J <br /> Q 16. <br /> U <br /> GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> .� 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 /> ynational government regulations. <br /> Q 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 <br /> O n be )ccncrnicai;y practicable and that I have select-,?d the practicable method of trestmenl,storage,or disposal Carrently available to me whict;minimizes the <br /> } present and future threat to human health and the environment;011.it I am a small quantity generator.I have made a good faith effort to minimize my waste <br /> U generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> LU Printed/Typed Name Signature Month Day Year <br /> 0 % <br /> • <br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> Z <br /> ZA Printed/Typed Name Signature Month Day Year <br /> LL S <br /> O p <br /> w O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> to <br /> < R Printed/Typed Name Signature Month Day Year <br /> U E <br /> Z R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> ! 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 NameGl y�_�. Signature Month Day Year <br /> 1, , t. <br /> DHS 8022 A(1/88) Do Not Write Below This line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />