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Form Appcoved OMS No.2050-0039(Expires 9.30.99) See instructions on bocic O e b. Department of Toxic Substances Conn. <br /> • <br /> Please print.or type. Form designed for use on elite(I2•pikb) rifer. Sacramento,California <br /> 1. Generator's US EPA 10 No. Manifest Document No. 2. Page I Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> is not required by Federal law. <br /> WASTE MANIFEST I 7C2 I <br /> of 1 <br /> 3, Generator's Name and Mailing Address �? <br /> �rl,,A ���� S N rtr <br /> ,Y\ � 29-5•377 <br /> ( S!v ) 16 <br /> C�- �Slo 't7 <br /> sA d. Generator's Phone r.7�' ,r <br /> N 5. Transporter 1 Company Name 6. US EPA 10 umber .. <br /> CLEARWATER ENVIRONMENTAL <br /> g CAR0000070113CP IRT-85tt" w - :::1- <br /> 7. Transporter 2 Company Name 8. US EPA ID Number <br /> Q <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number Sto �adl <br /> ALVISO INDEPENDENT OIL ,t T. <br /> 5002 ARCHER STREET - = <br /> cytALVISO,CA 95002 CAL 10 0 0 1 6 1 17 (4 3 St0 .79T-85it <br /> Q 12. Containers 13. Total ld Unit <br /> 11. US COT Description(including?roper Shipping Name,Hazard Class,and ID Number) No. Type Quantity wt/Vol P-Wasta•Number_ <br /> Z <br /> �3 G Non-RCRA Hazardous Waste Liquid 0 0 1 TIT G <br /> f <br /> cki E b. States: <br /> o N <br /> co <br /> R I I I EPAIOrhea <br /> i fuG <br /> -r A C Slag <br /> o T <br /> m O EPA/Other, <br /> R I I II <br /> a d. <br /> State. <br /> Z EPA/Other <br /> LU <br /> V I I 1 <br /> Addinanal:Descriptions.fotaMateirid ssteckAbays» t"t " xditr tf rHandrngiCodea.foeWa-Ie Usted.Abova <br /> Uj � ......3, a.shat ; ..;.:. ..' -+i,v .... t. •.,. a !..�+��"" :"7� it � � . <br /> 0 15 Special Handling Instructions and Additional Information <br /> WEAR PPE <br /> Z Emergency Contact:(510)797-8511 Attn:Krk Hayward <br /> = ERG# /7 <br /> t— <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> U <br /> If I am a large quantity generator,I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical] <br /> y <br /> a practicable and that I have selected the practicable method o�treatment,st or disposal currently to me which minimizes the present and Future threat to human health <br /> N <br /> and the environment;OR,if I am o small quantity generator,I have e o goo ith effort to tmize my este generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O Prin Typed Name <br /> e Sign' e P Month Day Year <br /> U <br /> ' trJj 1t� t D I I�7 c' <br /> tL T 17. Transoorter I Acknowled emanf of 12- t of Materials <br /> R Month Day_ ar <br /> � p Printed/Tv ed Nome Si nature I G/'� <br /> LLJ <br /> lry <br /> 0 0 18. Transporter 2'Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> zu E I <br /> to R <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A , <br /> c <br /> I <br /> L <br /> 1 20. Foci ity Ownerdr OpisrAr er ficatio fdjLceigt of hazardous materials covered by_l�iIPmiq*&st40bot aso0ted in Item 19. <br /> T Printed/Ty d me - Sign Month Day Year <br /> Y <br /> DO NOT WRITE BELOW TH NE. <br /> White: TSOF SENOS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(d/97) To: P.O. Bax 3000, Sacramento, CA 953:2 <br /> EPA 8700-22 <br />