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State of Colifornic—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-94) See Instructions on back age 6. Department of Toxic Substances Control <br /> Please print or type. Forth designed for use on elite(12-pitcnr.xpewriter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM, HAZARDOUS _ is not required by Federal law. <br /> WASTE MANIFEST C A L 0 0 Q I.' 0 .,(� ! Y� i�',�.(�� 4 0 3 of 1 <br /> 3. Generator's Name and Mailing Address t r', „'s A. State Manifest Document Number <br /> ` ULTRAMAR. INC. <br /> 92215492 <br /> 5?5 West Third Street, Hanford, CcA,`IIIt9s3Fg0 e� 1: 56 <br /> ''�J B. State Generator's ID <br /> r j 4. Generator's Phone 2 d 9 ) 583-3347 H 9 13 16 - 10 10 16 11 11 12 <br /> co <br /> p 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID <br /> 00 O <br /> H & H Shia Service Company ) ) 4 7 7 2 1 5 D. Transporter's Phone (415) 543-4835 <br /> Q7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> V <br /> F. Transporter's Phone <br /> Q 9. e' na24 a ili Name and Site�ddress 10. US EPA ID Number I G. State Facility's ID <br /> NZ H �i��u erg:ice tympany D 0 0 4 7 7 1 1 b 8 <br /> �O 220 Terry A. Francois Street !'isf,ao 543-4835 <br /> l*LL H. Facil' s P e <br /> a San Francisco, CA. 9411}7 7 7 7 1 1 8 <br /> J U 12. Containers 13. Total 14. Unit <br /> Z- 11. US DOT Description(including Proper Shipping Name, Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. W ste umber <br /> �~ R'ESTD,UF GASOLINE TANK star <br /> C)3. G NON•-RCRA HAZARDOUS WASTE SOLID 0 0 1 T P 1 0 0 0 0 P EPA/Other <br /> c'i E <br /> w e itS I II-E CASCL I(1c RjEL D I SPB,a;ff6 5t�512 <br /> CN R W4-FUA I'"AZAF1�.I'�' .1�� SOLI D 00 � t. P O Q P EPA/Other <br /> 181010 <br /> o A <br /> O T C. State <br /> 00 O <br /> � R EPA/Other <br /> w <br /> Z d. State <br /> Z <br /> w <br /> U <br /> �•- EPA/Other <br /> i� <br /> .�4�gg��tt1ongl Nes 'Ins for(v1 erials listed ABove K. Handling Codes for Wastes Listed Above <br /> LIMY`I` 111t� t'�r31. On tan K }vast containing a Qi b. 01 <br /> gasoline. Tank inerted with dry ire for <br /> Uj <br /> transport. d. <br /> a <br /> PROFILE #A2566 C. <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> JOB #12302 JOB SITE: BEACON STATION. 9494 <br /> Z 24 Hr. Emergency Contact: H R H 4(415) 543-4835 2185 E, Fremont Street <br /> = APPROPRIATE PROTECTIVE CLOTHING AND RESPIRATOR Stockton, California <br /> F- <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> Qpacked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> U <br /> 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 to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> FL <br /> N threat to human health and the environment;OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that I can afford. <br /> '` n Mo Q Day, QYear 3 <br /> 0 Printed/Typed-Nagle -Siggatare 6 <br /> \ '� �.— <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> 1 <br /> LU N Printed/Typed Name Signafu�l`[. �-} ,-�`%� �y /; r.� j�Morrt� 0 Da-8 QYear'j <br /> LURED 7 1' ` <br /> Y <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> wT Printed/Typed Name Signature Month Day Year <br /> LL <br /> 0 R <br /> LL 19. Discrepancy Indication Space <br /> V) <br /> Q F <br /> U A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Ce g' tion of recei t of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Ty a Signature Month Day Year <br /> D OT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (12/91) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 oroduca completed copy of this roov and send to DTSC within 30 days.) <br />