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$Iota el co,;fernie-•Err.ironmerdol Pr°fio"Agency see Instructions on back of- ige b. Departmad of Toxic Subs1°"°rs C°^fr°I <br /> M <br /> Form Approved omg rio.2050-0039(Expires 9-30-94) N % j Saapnenfo,California I <br /> -� Please print'or type. Form designed for use an efife(12•pita. Nrtbr' f <br /> Generators US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS .s not required by Federal law. <br /> WASTE MANIFEST CAD 9 8 1 6 9 6 4 2 0 0 2 i S 2 1 of i <br /> r. 1 <br /> E 3. Generators Name and Mailing Add rfI <br /> :ee 1 14e - o s 8' <br /> 30a347 aM rR LIf- �- <br /> C4 4. Generators Phono { <br /> 9�b �5I <br /> 3 TranspoAer 1 Company Name6. US EPA ID Number <br /> g � � 981696420 <br /> 7 7Z-. oder 2 Comparry Name 8. US EPA ID Number <br /> U N� <br /> P <br /> : <br /> Q 9 D`�r�narod Fadi Nome and Site Address 10. US EPA ID Number <br /> PAT�LRSOi�1 <br /> CVo 13331:. .•'RWY. 33 <br /> PATTS4H, CA. 95363 1A 10 18131116 16171218 <br /> Ma <br /> u yy F.,, :• 12. Containers ' :13. Talal. _•' 14. Unit <br /> 11. US DOT_beycripfion(including Proper Shipping Name,Hazard Class,and ID Number) No. T Wt of <br /> YM <br /> Z ._ � - <br /> a77 <br /> 13 ,; <br /> NON RCRA HAZARDOUS WASTE LIQUID 0 0 1 T T G <br /> C, E <br /> a�a N b <br /> Cc E <br /> C4 R <br /> T c- <br /> C9 <br /> 0 <br /> w R' " <br /> Z d. }_ <br /> W <br /> V <br /> w <br /> w <br /> J <br /> a <br /> 0 15. Special Handling Instructions and Additional Information ' <br /> 1= <br /> Z OILY WATER <br /> Uj <br /> -+ 16. GENERATOR'S CERTIFICATION: 1 hereby declare than the contents of the consigmnew are fully and accurately dexn'bed above by proper shipping name and are classified, <br /> Qpocked,marked,and labeled,and are in all respects in proper condition for tranpoit by highway according to oppPicable federal,state and irtemaWnal laws. <br /> N [am a large quamfy generator,I codify 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 /> economi[alhy 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 /> throat to human health and the emnronmenfi OR,if I am a small Quantity generator,I hove made a good faith effort to minimize my waste generation and select the best <br /> tY <br /> waste mon mend method that is available to me and that I can afford. <br /> 0 Printed/Typed Name Sig ro ` Momh Day Year <br /> L) '1 2 <br /> Z V, 17. Trans r 1 Acknowledgement of Receipt of Materials <br /> ' � .N Printed/T d Nama . � f} , �� - Signature ��_ I" _ , �Day r <br /> 37 <br /> '0 18. Transporter 2 Acknowled emend of Receiptof Materials <br /> V LL T PriMed/Typed Name Sig re Month Day Year 1 <br /> 0 .� <br /> LIJ 19. Discrepancy Indication Space }j' <br /> VF <br /> A <br /> Z_ C _ <br /> 1 <br /> • k <br /> p 20. Fccil!IX Owner or Operator Ceiiifitation of receipt of hazardous materials courted by this manifest e: as noted in Mem 19. <br /> t T Pouted/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC W22A (12/91) To: P.O. Box 400, Sacramento, CA 95812-0400 <br /> EPA 8700-22 <br />