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e of California—Health and Welfare Agency On BBCk 01 i'we 6 Department of Health Services <br /> n Approved OMB No.2050-4039(Expires 9.30.91) "? U ront o1 Paye 7 Toxic Substances Control Division <br /> ise print or type. (Form designed for use on elite(12-ptrc. er) Sacramento,California <br /> 1 <br /> UNIFORM HAZARDOUS 1 Generator S EPA ID No. Manifest 2. Page Information in the shaded areas <br /> WASTE MANIFEST C :'� C 0 0 0 2 216 ,91211 ODt.nCnlTo.j 1 of 1 <br /> is not required by Federal law. <br /> 3. Generator's Name and Meiling Address A. State Manifest Document Number <br /> TI KK�I�LAGUN 8 9 F i P 191 <br /> 4'Ce�e'(e'foN Ahdne Nn STOCKTON, CALIFORNIA 95206 B. State Generators ID <br /> 5. Transporter 1 Company ame 6. US EPA IO Number C. State Transporter's ID <br /> FALCON ENERGY IC A D19 1812 ,5 1216181517 D. Transporter's Phone <br /> 7. Transporter 2 Company Name8. US EPA ID Number E. State Transporter's IO <br /> CALIF. OIL RECYCLERS CAD 9 8 0 6 9 517 6 1 F. Tranaporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> EVERGREEN OIL C i4 D 9 8 O 8 8 7 4 1 8 <br /> 6880 SMITH AVENUE H. Facility's Phone <br /> N 8 018 18 17 4 1 0 (41-5) 795 4400 <br /> 12. Containers 13. Total 14. I. <br /> 11. US DOT Description(Including Proper Shipping Name.Hazard Class.and ID Number) Ouantity UnitWaate No. <br /> No. Type Wt/Vol <br /> a. State <br /> HAZARDOUS WASTE, LIQUID,N.OrSr, ORM—E343 <br /> IMM='9189 - 614 0 0 1 TIT 0 0 0 3 0 G EFj1/Other <br /> tXEWT <br /> State <br /> EPA/Other <br /> C. <br /> State <br /> =U <br /> C _ EPA/Other <br /> d. State <br /> EPA/Other <br /> J. Additional Descriptions for Materiall►L'Iated Above �� K. Handling Codes for Wastes Listed Above <br /> RINSEATE WASTE WATER_ a. <br /> b. <br /> C. d. <br /> 15. Special Handling Instructions and Additional Information <br /> 16. <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 certily that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> 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 ruture threat to human nealth sno the environment;OR.it I am a small quantity generator.I have made a good faith effort to minimize my waste <br /> generation and select the best waste management method that is available to me and that I <br /> Printed/Typed Name Signature Month Day Year <br /> 17. Transporter 1 Acknowledgement of Receipt of Materials -- <br /> Printed/Typed Name Signature Month Day Year <br /> 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> Printed/Typed Name Signature Month Day Year <br /> 19. Discrepancy Indication Space <br /> 1 1 , <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br />-(1/66) <br />-22 Do Not Write Below This Line <br /> Previous editions are obsolete lair rSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 3000, Sacramento, CA 95812 <br />