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Stale of California—Health and Welfare Agency Toxic Substances Control Division <br /> Fotfin Approved OMS No.2050-039(Expires 9.30-91). Sacramento,California I <br /> Please print or type. (Form designed for use on efif itch typewriter}. ; <br /> UNIFORM HAZARDOUS 'nerator's US EPA ID o- Manifest 2. Page I Information in the'shaded areas <br /> WASTE MANIFEST C 1) LO �� _ �gSurq�nt�o.y ut 1 is not required bylFederel law. ` <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> JCt •� � � !J j <br /> 1 N �AM UI I I P r rUS B. Slate[ierterator'�� � 'v r ' <br /> 175 GWV'IT LIPS R) TPVXY CCS! 9537 I. <br /> r <br /> 4. Generator's Phone( ) ..r1011 M 21 P <br /> 5. Tran�poner 1 Cempan Name 8. US EPA ID umber t5 C. State Transporter's ID <br /> �I!!.#LEt f Tl rkI�fiG C A 1) 9 S 0 8 5 7 �}v U D. Transporter's Phone <br /> cv <br /> 'O T. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's fD <br /> CO <br /> F. Transporter's Phone . <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Slate Facility's ID <br /> I i ; UNICES OF CALIFOMIA FNI <br /> r,UH. Facility's Phone <br /> BU <br /> T U,j ILLt i CA 93�Pfi CAL' 6 7 5 21716 8U5-762-7341` <br /> 12. Containers 13. Total 14. I. <br /> ~O0 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity 'Unit Waste No. <br /> ALL No, Type Wt/vol <br /> ?V a. State <br /> G OILIMN41A REGULART WASIL ONLY W1 RCPA 001 U T G 0 0 2 C Y CLU 1 <br /> F E <br /> t.} N <br /> E b. State <br /> R % <br /> A <br /> T EPAIOther <br /> N <br /> o <br /> O R C. - Stale <br /> EPA!Other <br /> wd. <br /> � State <br /> Z <br /> Wu1 1 <br /> EPA!Other - <br /> W <br /> Z J. Additional Deacriptfons for Matertsls Listed Above io K. Handling Codes for Wastes Listed Above <br /> . 13-u SOIL C€NTAMIMTED WITH OIL a GFUSE <br /> OC <br /> C. d. <br /> J <br /> a <br /> O � <br /> r– 15. Special <br /> 1f M <br /> all(Handling Instructions and Additional Information <br /> Z F,rvVl ILE — U <br /> #LAR GUNES, WU-"-S & Pwi(TIVE IM EWIRENT <br /> J <br /> J <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare thal'the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked.and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> national government regulations. <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 1 have determined <br /> O to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the <br /> } present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith effort 4o minimize my waste <br /> CCCZZZ��] generation and select the best waste management method that is available to me and that I can afford. <br /> Lu Printed/Typed Name ; Signature -- - Month Day Year <br /> � 1! <br /> LU R 17. Transporter I ACknowfedgement of Receipt of Materials <br /> C N PrintedlTyped Name '1 Signature Month Day Year <br /> P PP <br /> LU O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted In Item 19. <br /> T <br /> y Printed/Typed Name Signature Month Day Year <br /> OHS 8022 A(Il88) Do Not Write Below This Line <br /> EPA 8700-22 <br /> (Rev.9-88)Previous editions are obsolete. <br /> YELLOW: GENERATOR RETAINS <br />