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State ofCalifornia—HealthrovMBNo.2 and Welfare Agency Department of Health Services <br /> Form Approved OMB No.2050-0039(Expires 9-30.91) Toxic Substances Control Division <br /> Please print or type. (Form designed for use on elite(1 .ch typewriter). Sacramento,California <br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> Document No. <br /> WASTE MANIFEST 41611,17 of Is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> ULTRAMAR, INC. (Q� <br /> 3300 WATERLOO ROAD STOCRTON,:aC�w., 95005 B. State Generator's ID <br /> 4. Generator's Phone( ) <br /> h6. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's ID (5 S" <br /> HAVCONTROL, INC. <br /> N IC D D. Transporter's Phone <br /> W) 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> 0 <br /> F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> HAZ/CONTROL, INC. ��, � <br /> 731 RENT' LANE e 1A ID H. Facility's Phone <br /> 0 10 16 12, <br />�.Z GILROY, CA 95020 <br /> X)M CAI <br /> 0 12. Containers 13. Total 14. L' <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br />', Z a•IfAZA,ehov r, W4 7C 0,,11 xj.. cl State <br /> G <br /> 3 N i�/rr vJ0FJ c © IPA/Other <br /> E b. J i2 <br /> N R State <br /> A <br /> m T <br /> N O EPA/Other <br /> a R c <br /> State <br /> OD <br /> EPA/Other <br /> M <br /> W d. <br /> Z State <br /> W <br /> U <br /> W EPA/Other <br /> 03 J. Additional Descriptions for Materials Listed Above <br /> ZK. Handling Codes for Wastes Listed Above <br /> b. <br /> W <br /> c• d. <br /> a � , <br /> 0 <br /> Q16. Special Handling Instructions and ditio�olal Information z� ®� <br /> Z EMERGENCY CONTACT t + ��" <br /> W <br /> J WEAR PROTECTIVE CLOTHING AND SAFETY GEAR. <br /> Q 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 /> CL national government regulations. <br /> If 1 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 <br /> 0 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 future threat to human health and the environment;OR,if 1 am a small quantity generator,1 have made a good faith effort to minimize my waste <br /> Z generation and select the best waste management method that is available to me and I can afford. <br /> 0 Printed/ Name Signature Month Day Year <br /> W <br /> WTR 17. ransporter 1 Acknowledgement of Receipt of Materials <br /> QA Print ed Namenat <br /> W N g ure Month Day Year <br /> 0 S . <br /> W 0 18. Transporter 2 Acknowled ement of Receipt of Materials <br /> co Q R Printed/Typed Name <br /> U E Signature Month Day Year <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> i <br /> IUN <br /> L 1 � i <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous m t e It i►est except as noted in Item 19. <br /> T <br /> Printed/Typed Name <br /> i�atpS$/t�eC Month Day Year <br /> DHS 8022 A(1/88) Do Not Write Below This line <br /> EPA 8700-22 Blue:GENERATOR SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (Rev.9.88)previous editions are obsolete. To:P.O.Box 400,Sacramento,CA 45812-0400 <br />