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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back `age 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pit iwriter. Sacramento,California <br /> I. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS ;'ti , —1 G� s not required by Federal law. <br /> WASTE MANIFEST ( U } ` J of 1 <br /> 3. Generator's Name and Mailing Address ? j '.,�' � ,-•<� A. State Manifest Document Number 21807002 <br /> O �✓ .� J �. /- B. State Generator's ID <br /> 4. Generator's Phone I a't~� I ! �''{�' �i 't Y �Ui �, r' .,U <br /> t\ <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> u7 <br /> O L1Fj-L!� ICAN +IA,1 f EY WASTEO!L, C A t U d (J 8 2 7 7 D. Transporter's Phone <br /> O <br /> op 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> QF. Transporter's Phone <br /> U 9. s e s 10. US EPA ID Number G, Stato-Fac]y ID 4 <br /> :� 3�RY��i��Y�:bin c°�;bIOYrL i-i V silty"t 1 n a �� a t <br /> M " V <br /> CD Z .5JUO CLAUS ROAD H. Facilit 's Phone <br /> q O RIVCRFIANK, CA 91,5367 C I A I L 0 6 11111 fl 1 D 1 (3 209-863-81811 <br /> JQ12. Containers 13. Total 14. Unit <br /> �•v V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. I Tye Quantity Wt/Vol I. Waste Number <br /> Z I a It <br /> NON-RCRA HAZAii0i7�.i.G�fltA3 E {.;QUIET State •1'1 <br /> S _ <br /> 3G ( OILY WATER } 01 G 1 1 T Ci EPA/Other <br /> o N b' State <br /> 00 <br /> co E <br /> R EPA/Other <br /> A c. State <br /> o T <br /> aao O <br /> R EPA/Other <br /> ae <br /> Lu d. <br /> State <br /> Z <br /> Lu <br /> V rEPA/Other <br /> Lu <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> p OILYYtATP'.ti iJ'! b. <br /> � r <br /> Lu <br /> ce c. d. <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> a GLOVES <br /> Z EM ER-G"NCY PHONE 20"67-8857 <br /> Lu <br /> 2 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantiy 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 economically <br /> d practicable and that I have selected the practicable method of treatment,storage,or disposal currently available t Mich minimizes the present and future threat to human health <br /> N and the environment;OR,if I am a small quantity generator,I have made a good faitha fort to mini waste generation and select the best waste management method that is <br /> °C available to me and that I can afford. <br /> rt t <br /> :. , / <br /> >_ Printed/TypedName Signature ' k_, onth� �'ppy/ Year jt <br /> Z if 712 / �e2 <br /> w T 17. Transporter 1 Acknowledgement of Riceipt of Materials <br /> C7 R <br /> w p Printed/Typed Nome"r-�-- Signature /; � f•10 thJ }Day i-Year <br /> Lu <br /> u_ p 18. Transporter 2 Acknowledgement qf Receipt of Materials <br /> T Printed/Typed Name Signature Month Day Year <br /> w E <br /> N R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by4hrimanifq except as noted in JtenIE,". <br /> YPrinted/Typed Nti Signat� fy]/on� / Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> Green: TRANSPORTER RETS <br /> EPA 8700-22 <br />