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Gepenmeou�t nva � �� <br /> State of Californe—Health and Welfare Agency Toxic Substances Control I <br /> Form Approved OMB No 205o--0039(Expires 9 30 91) Sacramento Cahtomi <br /> PtPt+aase print or type (Form designed for use on elite(12 pitch typewriter) Manifest 2 Page 1 Information in the shaded areas <br /> V UNIFORM HAZARDOUS t Generator a US EPA 10 No Document No <br /> L of Is not required by Federal law <br /> WASTE MANIFEST A. Slate Manifest DDcuiriailt N mf3er� <br /> . 3 Generator a Name and Medi ddr sa 8 a(i� ((VV�� 3Vd 7 <br /> 714X�A/ 14V4 toy A�6 foe <br /> B S1aH Generator a ID <br /> 4 Generator s Phone(7_1j) B /00 q o <br /> g US EPA lD Number G State Transporter a 1D O <br /> 5 Transporter 1 Company Name p Transporter a Phones, <br /> A IDN <br /> 1- ar r`{+ 8 � x ¢ E Stats Tranaporter's YD <br /> C4 <br /> 7 Transporter 2 Company Name US EPA 1p Number <br /> F Transporter s Phone <br /> G State Facility a ID <br /> 9 Designated Facility Name and Site Address <br /> 10 U5 EPA tD Number <br /> J Ref ineries Service H Facility s Phone <br /> 13331 N. HWY. 33 (209) 800-874-4444 <br /> 1� < PaLterson, CA. 95363 <br /> 12 Containers 13 Total 1 1 <br /> Quantity Unit <br /> it Waste No <br /> 0 11 US DOT Description(Including Proper Shipping Name Hazard Class and ID Number) No Type WI/Vol <br /> Stale 223 <br /> W v a 0 0 TT G <br /> Non RCRA Ha'LardOU3 Waste Liquiu EPA IOther <br /> cr) z a 00 <br /> E State <br /> N <br /> E b <br /> � R EPAIOther <br /> CO T State <br /> v O <br /> t01 R e EPA/Other <br /> I State <br /> ' Wd <br /> F EPA!011ier <br /> Z <br /> W <br /> U <br /> K Handling Cedes for Wastes listed Above <br /> XJ Additional Descriptions for Materiels listed Above a b <br /> o Petroleum HydrOcarbonsAPROX % < o <br /> In <br /> Water APPROXI c d <br /> LU! Sludge APPRUX /R% <br /> J 1 <br /> a <br /> z <br /> 15 Spe�al Hend]�y Instructions and Additional information <br /> a 4Ye¢T' liiOVe.l Be Goggles <br /> Z <br /> w <br /> J <br /> 4 (� 1$ <br /> GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accuratelyditlan for transport 6y highwayy acabove proper shipping name <br /> ' and are classified packed marked and labeled and are In all respects in proper connecor d ordinq to appplicable international and <br /> J <br /> Nnational government regulations <br /> U) 11 1 am a large quantity generator I certify that I have a program in puce to reduce the volume and toxicity of waste generated to She degree I have determine <br /> to be present and'(uturaylhrent 1 ble and human healtI have selected the h and the environment practicable <br /> 1 m a malltquantitytgenerattor I haystorage Or e made a g000sal d faith effort to mtnIn a mavailable to me which y waste <br /> present <br /> U generation and select the best waste management method that is available to me and that I can afford Month Day <br /> Printed/typed Name �� <br /> LU •�L�'.C=Lc o <br /> WT 17 Transporter 1 Acknowledgement 01 Receipt of Materials Month Day <br /> C A Pd (Typed Name Signet e / /10161,Ot <br /> 18 Transporter 2 Acknowledgement oT eeeipt of Matenals Month Day <br /> 4 R Signature <br /> 7 PrkntedlTyped Name <br /> C1 E <br /> Z <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> . C <br /> l <br /> L <br /> I 20 Facility Owner or Operator Certilication of receipt of hazardous materials covered by this manifest except ea noted in Hem 19 <br /> Month Day <br /> T Signature <br /> y Printed/Typed Name <br /> (I 188) Do Not Write Below ThtS line <br /> DHS 8022 A <br /> EPA 0700-22(I Blue GENERATOR SENDS THIS COPY TO DOHS WITHIN <br /> (Rev 9 88)Previous editions are obsolete To P 0 Box 400, Sacramento, CA 95812 0400 <br />