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State of Californio—Environmental Protection Agency <br />' Form Approved OMB No 2050-0039{Expires 9 30 991 See Instructions on back of page b. Department of Toxic Substances Control <br /> Please print or type Form der.gned for use on afire(12 pitch)typewriter Sacramento California <br /> 1 Generator s US EPA ID No Montle f ocu ant No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS 1} ` I is not required by Federal law <br /> WASTE MANIFEST L r OR t �1 of <br />' 3 Generator s Name and Mailing Address "Stella hh` tfa;I f)a umdn $ b t + t <br /> if <br /> 4. Si 6 1 I v D a an <br /> o i <br /> -p] q # [ ag &litlpieperao]i3>F'�I� t n ,� 1, x <br /> r� ! r lyf '! ail' M, y��tr., gr`i� '�' FY"r•,ki7. <br /> � 4 Generators Phone7�'x �'� � i <br /> h a s <br /> tV 5 Transporter 1 Company Name 6 US EPA ID NumberC" flste roll p¢rtti?,% 4 m .' <br /> CCo fkME"�ICANV`ALL.E;Y'tr:1dA5TEOIL. G A L 0 0 0 8 2 8 7 81 � � x__ ��r,; � <br /> V <br /> 7 Transporter 2 Company Name B US EPA ID Number >m$EQf9s 1� bs orfgY s ° sa tMv <br /> SP, •'d 'fr'9. 'ic <br /> Q '1✓anepph' n+ .'��' ", d- t <br /> U i r s 10 US EPA ID Number G' SR-,$77w�i k+ V tiJ <br /> rrrFi y M VIP,f.(sd <br /> r-3M CLAUS ROAD <br /> RIVERBANK. CA 96367 C A L 00 0 1 9 OS 1 $ �'���� u x "!16r"�A,"�� <br /> 'Y Gw ak ry iE <br /> Q <br /> 11 US DOT Description(including Proper Shipping Name,Hazard Class and!D Number coo <br /> !2 Containers 13 Total 14 Unit -� � <br /> U f g p pp g 1 No T e Quantity Wi/Vol ,t a '� mb rfi <br /> a <br /> svIs <br /> _ ( OILY WATER ) 0 0 1 T T O ��; <br /> } 3 Gc14 E <br /> O t d P <br /> o N b <br /> 0O00 E <br /> v Ria � �f; , <br /> w <br />' 6 T t <br /> o T " <br /> co O <br /> Ra r�. <br /> 1LUw d z . <br /> � ELU <br /> �.�x���� <br /> 1 Adifihanol(Seicn}at�ryops r M fie `I+t'j}etJ+�1{�oYe A R r s ° ai ri ., a" a! a57 < <br /> r h, -�' -a d' ,v .�, r .sd ' ' exr �` 'iti fidN>Ea.� od� r r4sf�s'rkrsted,yF46osTe' qe <br /> it k k� " <br /> w <br /> X 4_ <br /> 3.a �, � ,�� �� r m ✓,� �� .e". y, "� �r .d� a E +w'tr `��t 3 w' r�,� � f'"� <br /> it a qy� <br /> LU F atd� ,3't��"''t e � i��t' h '�c, �-f^`� a�wh��'f'�i� `e, <br /> v h <br /> dye r .t figs -3- <br /> e �, r" �L. ' .,+, ` 'm "' 9'y:s; u 'i�.�r.J i G ,'.Jt •,� ��� :� '��.� x� �y rt,¢ <br /> O 15 Special Handling InstructionsandAddthonal information <br /> a GLOVES <br /> Z 15MERGENCY Pli41w?NJE 209--EI87-88617 <br /> F <br />' w <br /> Q 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of thu consignment are folly and accurately described above by proper shipping name and are classified packed, ri <br /> U marked and labeled and are m all respects in proper condition for transport by highway according to applicable international and national governmant regulations <br />' If I am a Sorge quonhy generator I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and That I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> en and the environment,OR if I am a small quantiy generator I have made a good faith effort to minimize my waste generation and select she best waste management method that is <br /> F'= available to me and shat I can afford <br /> O <br />' y Prints typed Name Signature Month Day Year <br /> w <br /> 61 ,91101 Z- <br /> 0 RT 17 Transporter 1 Acknowledgement of Receipt of Matariols <br /> LL, <br /> A Printed/Ty ped Nam t Signature Month Day nYear <br /> LU P l�"d <br /> LU 0 4J 7- <br /> U- 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name Signalure Month Day Year <br /> LLA E <br /> Q R <br /> U 19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I 20 FacilityOwner or Operator Certification of receipt of hazardous materials covered by thi moniFest except as noted in Item 19 <br /> 7 Printed/Typed Noma Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTA[ 0 (1/99) <br /> EPA 87700-0-22 Yellow GENERATOR RETAINS <br />