Laserfiche WebLink
State of Colifornia—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039 f Exprres 9 30 99) See Instructions on back of page 6. Department of Toxic Substances Control <br /> Pteo.e print or ype form designed for use on vlife(12 Poch)ypewnler Sacramento California <br /> 1 Generator s US EPA ID No M niFes}�10 en!No 2 Page 1 Information m the shaded areas <br /> UNIFORM HAZARDOUSregwrad by Federal law <br /> WASTE MANIFEST <br /> 3 Generator s Name and MailingAddress y�1ST �y ASt¢tg'fl�pnyfas}bn6ulsidtrf�lJu bar9rr ° � ���C1 <br /> a14 ck, e n� �u 'fir � ✓]aft <br /> s' <br /> LO 4 Generator's Phone ��`"� dd ♦� ,, !! �d ( /�/_ �d t <br /> CV 5 Transporter 1 Company Name 6 US EPA ID Number C;5m1e,7rclns ctttar^i'1DYRd"erveifk}iw nti�v ti <br /> � I�� �` p Y r 0&e� �u <br /> 60 ,,AIS VPNL EY WASTE OIL G A L 0 0 Q 8 2 7 13 8. <br /> O D QFcnpartar ''�;� <br /> s 'soPliaeie'R� y, <br /> 7 Transporter 2 Company Name 8 US EPA ID Number - P$ riq <br /> O0 6 �E Se6ie I'a po r s�ID" R>�ierve`d <br /> Lao Fs Tana arse ysF Rhos}, <br /> n r t <br /> i r 10 US EPA ID Number <br /> zt �vrr <br /> a It <br /> 6�10D CLAUS #BOAC) �'1 t l •K � h `�' "''a� , 'r� ; <br /> RIVCRBANKr CA 95,3�i 0 A L O 0' 0 1 9 0 8 � S�' Fa411�1�aI�- ` <br /> J r wCr ,s JW d <br /> si ``a ,� > tt� `n cr" ; of Aaf G <br /> UP { 9 P Skipping I 12 Con!ainers fTot;Q14 Unit y = '��11 US bOT Descn flan indudm Pro er Shi m Name Hazard Class and ID Number No T eWi/Vol 1i �Wf sta N mbeT'vs <br /> ( OILY WATER ) 004 T IO <br /> E � a Y` <br /> CIA N bco <br /> �r <br /> FE�k�Ot�terf <br /> O T <br /> C> OGo <br /> R ,4EPajG3ifl�� <br /> '4 <br /> U-1 dLU <br /> 5t4Fe �° e <br /> (CEPA t♦18rrt+r, S r ro "" <br /> LLJ <br /> N J ttonahDI- ad r <br /> `escrl `sgf�p[q��{Ja pled above }" ar I 4 e ", „ � 4 k '19 HdeicicV F{les Llsled Afsavo <br /> >, W Add �Bq�� <br /> 1 o� <br /> n. �,y <br /> LU 51 .� uF",y "''.. .tr'� .st° rf �" Wti it '¢ r��"�'i 'x' 53 r'a 'ri ° "t�"' d 'a g � i(j ^a" %,'"F a h°"""�S'-.' r �� `eF,_+�✓,,:kap <br /> a' a ✓' sr F` rT�` "1, <br /> .d <br /> 15 Special Handling Instructions and Additional Information <br /> a <br /> GLOVES <br /> Z F#IERGENCY PI-IONE 20*"IV- 8157 <br /> Lu <br /> 1 16 GENERATORS CERTIFICATION I hereby declare that the contents of this consignmen+are fully and accurately described above by proper shipping name and are classified packed, <br /> marked and labeled and are in all respects in proper condition for transport by highway occordmg to app,cable international and nattona government regulations <br />' J <br /> -+ If I am a large quantity genararor I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to rhe degree I have determined to be economically <br /> � practicable and that}have selected the eradicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> and the an "onmen1,OR if I am a small quantity generator I have made a good Faith effort to minimize my waste generation and select the best waste management method that is <br /> 0 available to me and that I can afford <br /> } Print Hyped Mamef Signature/ � � Month Day Year <br /> LU T 17 Transporter 1 Acknowledgement of Recei 1 of Materials <br /> w SPnnl;d yp d N�m+rpr �` Signatur Month �yDay /ryYear <br /> R (/' C�A'// 5 I �r 0 <br /> W P <br /> O0 18 Trans orter 2 Acknowled ement of Recei !of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> 11.1 E <br /> Q R <br />' U 19 Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> 1 20 facility Owner or Operator Certification of receipt of hazardous materials covered 6X this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> OL .I - - I I I I I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 00—22(1/991 <br /> EPA 87700— Yellow GENERATOR RETAINS <br />' <br />