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i <br /> ' I <br /> iomia–Health and Welfare Agency Department of Health Services <br /> ,oved OMB No,2050--0039(Expires 9-30-9 Toxic Substances Control Division <br /> print or type. (Form designed for use on eliteah typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2, Page 1 Document NInformation in the shaded areas <br /> o. <br /> WASTE MANIFEST7 2 of is not required by Federal law. <br /> 3. Generators Name and Mailing Address A. State Manifest Document Number <br /> Alex Gilliland 8 9 <br /> 3776 Grant Line Rd. Tracy, CA 95376 B. state Generator's ID <br /> 4. Generator's Phone( 20%-835-5530 H <br /> � 5. Transporter 1 Company Name 6. US EPA ID Number C. Slate Transporter's ID <br /> Refineries ServiceD. Transporter's Phone <br /> N <br /> Co7P9 892 6:7431 <br /> . Transporter 2 Company Name 8. S PA ID umber E. State Transporter's <br /> Co p <br /> O F. Transporter's Phone <br /> m <br /> I 9. Designated Facility Name and Site Address 10. US EPA Ila Number G. State Facility's ID k <br /> i Refineries Service B / 6 2� Iti <br /> �}0 13331 N. HWY. 33, Patterson, CA 95363 H. tility'sPhone <br /> —�z C.A I D 10 18 13 111616 1712 18 209-892-6742 <br /> Q 12. Containers 43. Total 14. I. <br /> t�O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Ouentity Unit Waste No. '. <br /> �•i No. Type Wt/vol j <br /> Hazardous Waste Liquid NOS ORM-R NA 9189 State I <br /> 3)z 223 <br /> F E EPA/Other <br /> N Q TIT 4 0� <br /> E b. State I <br /> N R <br /> O A <br /> m T EPA/Other <br /> N D <br /> I R C. State <br /> S <br /> EPA/Other <br /> W i d. State <br /> Z <br /> w <br /> L) EPA/Other <br /> w <br /> LO J. Additional Descriptions for Materials Listed Above <br /> Z K. Handling Codes for Wastes Listed Above <br /> O 9q C) a 01R b <br /> a <br /> Lu rinsate A'r�7C. a. <br /> O . t. <br /> 15. Special Handling Instructions and Additional lntormation <br /> Z <br /> W + <br /> J <br /> U <br /> a 16. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that 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 I have determined f <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 ;I <br /> } present and future threat to human health and the environment;OR,it I am a small quantity generator,I have made a good faith effort to minimize my waste yl <br /> V generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> Lu Printed/Typed Name Signal ; Month Day Year <br /> j <br /> W V I P.J Y) a - <br /> WT 17. Transporter 1 Acknowledgement of Receipt of aterials `_. <br /> Z R .. <br /> a A Printed/Typed Name -Signature - Month Day Year <br /> N G� <br /> LLS % f <br /> O P <br /> W O 1 Transporter 2 Acknowledgement of Receipt ofMaterials <br /> v7 <br /> R Printed/Typed Name Signature Month Day Year I <br /> O E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L � <br /> 'i <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 YearDHS ` <br /> 87 -22000 /68) DO Not Write Below This Line <br /> EPA 1 <br /> (Rev.9-68)Previous editions are obsolete. Blue: GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS III <br /> To: P.O. Box 400, Sacramento, CA 95912-0400 <br />