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State of California—Environmentol Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30-99) See Instructions on bac ge 6. Department of Toxic Substances <br />Please pint or type. form designed for use on elite (12 awriter. Sacramento, California <br />L <br />Z <br />r <br />3 <br />rY <br />W <br />H <br />Z <br />W <br />U <br />W <br />to <br />Z <br />0 <br />CL <br />in <br />W <br />Q <br />Z <br />0 <br />a <br />Z <br />W <br />H <br />Q <br />U <br />J <br />o. <br />N <br />LQ <br />u <br />Z <br />W <br />6 <br />Uj <br />W <br />W <br />LL <br />0 <br />W <br />v7 <br />Q <br />U <br />DO NOT WRITE BELOW THIS LINE. <br />UNIFORM HAZARDOUS 1 • Gen ra%o s U A ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br />is not required by Federal low. <br />WASTE MANIFEST <br />Y, <br />t oft <br />, <br />3. Generator's Name and Mailing Address t {� n' �� A. State ManifestDocument Number y <br />iL/M`, i�iV'r+I+f�(r1/ 2 96:44 <br />B. State Generator's ID <br />4. Generator's Phone ( I S <br />5. Transporter 1 Companl Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved,] <br />SAFETY—KLEEN SYSTEMS INC. T 0 00 0 30 I I I <br />D. Transporter's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E, State Transporter's ID (Reserved.) <br />Fr Transporter's Phone <br />9. Designated Facility Nome and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />050702 <br />9 AP 98 9 8 P 714,'1'13 1, 1! 1 1 <br />VERGREEN OIL INC <br />H Facility's Phone <br />880 SMITH AVE C 9 0887 18 <br />EWARK CA 94560 1 1 <br />510 795-4400 <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />I Type <br />o. <br />State <br />} <br />NON—RCRA HAZARDOUS WASTE LIQUID <br />G <br />OIL, WATER, SLUDGE( NOT DOT REGULATED) <br />TT <br />"�EPA <br />!1/� <br />E <br />N <br />b, <br />Slcw <br />E <br />R <br />EPA/Other <br />T <br />C. <br />Stole <br />® <br />R <br />EPA/Other, <br />'. <br />d. <br />State <br />EPA/Other .r <br />J. Additional Descriptions for Materials Listed Above <br />K. Hondling Codes for Wastes <br />Listed Above <br />. .. .. <br />4y .` <br />C _. <br />15. Special Handling Instructions and Additional Information <br />MFST R/T#000000000 0-000-00 <br />EMERGENCY <br />RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />K CORP AUTHORIZED .TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this constanment are fully and accurately described above by proper shipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and notional 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 t hove determined to be economically <br />practicable and that I have selected the practicable method of treatment,. storage, or disposal currently available to me which minimizes the present and future threat to human health <br />and the environment; OR, if I am a small quantity generator, I hove made a good faith effort to minimize my waste generation and select the best waste management method that is <br />ave a to me and that I can afford. <br />ri d T ped Nome <br />SignaturMonth <br />Day Yet <br />T <br />17. Trans orter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Printed/Typed Name <br />Signature <br />Monthay Ye( <br />�y <br />1013 <br />S" <br />1,11y V <br />0 <br />18. Transporter 2 Acknowled ement of Re ei t of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Yet <br />R <br />1/ <br />✓► 1 V <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />11 <br />20. Facility Owner or Operator Certification of receipt of hazardous moteriQls-co.yored by this manifest except as noted in Item 19. <br />T <br />e--- �"t t. <br />oture <br />Mont Day Ye( <br />WNome <br />���� <br />-h7 <br />DO NOT WRITE BELOW THIS LINE. <br />