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State of California—Health and Welfare Agency Department of Health Services <br /> Fnrm Approlled OMB No. 2050-0039(Expires 9-30-2011111111, Toxic Substances Control Division <br /> ` Please print or type. (Form designed for use on ell, Ditch typewriter). Sacramento.California <br /> UNIFORM HAZARDOUS ieneralor's US EPA ID No. Manifest 2 Page 1 Information in the shaded areas <br /> "� Document No. <br /> WASTE MANIFEST r of not required by Federal law. <br /> 3. Generator's Name and Mailing Address '� '- A. State Manifest Document Number <br /> D. S . S . Lajiri-srini 89460931 <br /> 690 I•T. CLa j SLOCI-toli, CA . B. State Generator's TO <br /> 4. Generator's Phone( ) <br /> to 5. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's ID <br /> rte. H'3.0�•S t' I','1'j i rl`?:�i'1!�:7 T,v i . 17 1, f� !� ij L; '� tj c ^ D. Transporter's Phone <br /> N <br /> 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's 1 <br /> OO F. Transporter's Phone" <br /> aD <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> RECYCLEPRON OIL, INC . Oo ! L(, 7 91 <br /> r-4-<j I333L North Highwav 3 H.lFec/iity'sPhone <br /> Q7 z fll t terso 1 , CA 9'36 S r � r. f' � t r c 0 12()C1 �� Z � 1 Z- <br /> ¢ 12. Containers 13. Total 14. I. <br /> G 0 11. US DOT Description(Including Proper Shipping Name,Hazard C1aas,and ID Number) Quantity Unit Weste No. <br /> No. Type Wt/Vol <br /> a. <br /> U State <br /> C"Z G Waste diesel/Combustible liquid MA 1993 EPA/Other <br /> CO N � t-� e— <br /> '� E b. State <br /> ii R <br /> A <br /> 00 T EPA/Other <br /> c 0 <br /> f 0 <br /> R C. State <br /> EPA/Other <br /> W d. State <br /> f– <br /> Z <br /> VEPA/Other <br /> W <br /> rnJ. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> j Q a. b. <br /> ar <br /> ' RECEIVED c. d. <br /> j w <br />' J <br /> Z <br /> I Q <br /> j 15. Special Handling Instructions and Additional Information <br /> W ENVIRONMENTAL HEALTH <br /> I <br /> PERMIT/SERVICES <br /> I J <br /> I � <br /> Q 18. <br /> U <br /> GENERATOR'S CERTIFICATION: I 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 /> d national government regulations. <br /> i <br /> ¢ If 1 em s lerpe quantity generator.i certify that I have s program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> O to be occnemicaily practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> >- present and future threat to human health and the environment:OR.if 1 am a small quantity generator.1 have made a good larth effort to minimize my waste <br /> U generation and select the beet waste management method that is available to me and that I can afford. <br /> i n Printed/Typed Name Signature Month Day Year <br /> i W T 17. Transporter t Acknowledgement of Receipt of Materials <br /> = R De <br /> A Printed/Typed Name Signature MonthY Year <br /> I o S ,4 . r",U — 1 ,61 1 4 1/1 )1 4n <br /> I W O18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> t Month De Year <br /> UPrinted/Typed Name Signature y <br /> I� Z E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I I <br /> f L <br /> t 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item t9. <br /> T �^ Month Day Year <br />; y Printed/Typed Name � 0. L'4 4 /7Z12 <br /> h'�- -('�Y �� Signature <br /> I 1 J C <br /> t1 <br />! DHS8022 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 />