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1 <br />State of Qblifornia—Environmental Protection Agency <br />)Cal <br />Ap j oved OMB No. 2050-0039' (E>Epires 9-30-99) See IT1SfrUC11005 AR bpC�C ge 6. Department of Toxic Substances Control <br />ease print or type. Form designed r u"se on elite (IZp tc, writer. Sacramento, California <br />of <br />w <br />Z <br />LUV <br />tw <br />O <br />CL <br />V) <br />w <br />J <br />Q <br />Z <br />O <br />Q <br />Z <br />vwi <br />Q <br />V <br />Z <br />DO NOT WRITE BELOW THIS LINE. <br />Yeilrn:r. GENERATOR RETAINS <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Mani fest Document No. 2. Page 1 <br />Information in the shaded areas <br />I <br />is not required by Federal law. <br />WASTE MANIFEST <br />C1 Al Ll 010101019181717121 a <br />of <br />3. Generator's Name and Mailing Address <br />A $tate Manifest f?ocUment Number <br />` <br />y� <br />Ii C R�lt®l <br />aA`"'' <br />P.O. BOX 886, BENICIA, CA 94510 <br />a staleGeneraloi�ID = .� <br />4. Generator's Phone ( 707J �(k5 .�5 <br />; k" <br />4 <br />-si 4Mr <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C.. State Trans rt6rsiDse <br />I_ <br />po . _ 0 <br />. Rerved.] t uh <br />D. Transporter's Phone <br />7. Transporter 2foMpanyR.Mme A ID Number <br />-57 <br />E. State Transporters ID'I eserve .j <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />RAMOS ENVIRONMENTAL SERVICES <br />H. Facility's Phone'' <br />1515 SOUTH RIVER ROAD, WEST SACRAMENTO CA 95591 <br />1 1. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/vol <br />1. Waste Number., <br />No. <br />Type <br />a. NON—RCRA HAZARDOUS WASTE LIQUID <br />Stater"_ <br />G <br />(OILY WA NAit96 % <br />EPAJOther, <br />Nb• <br />State <br />E� <br />EPA/Other <br />T <br />C. <br />State <br />O. <br />R <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />1, Addition I Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information j 7. <br />S LOCATION w <br />HANDLERS BE 40 DOUR OSHA/S A? INfrD <br />THE CUSTOMER ANY % STORE #37 <br />AND USE NIOSH APPROVED P 6 <br />15 E. CRANI` LIKE ROAD <br />EMERMOCY CD1ff=: (916) 321-S747 <br />TRACY, CA 95376 <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 />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national 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 1 have determined to be economically <br />that Ilthe treatment, disposal <br />practicable and selected practica6le method of storage, or 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 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Typed Name+ <br />Si�re <br />Month Day Year <br />Ll A4fl <br />T <br />It <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name i <br />ignoture <br />/e, <br />Month Day Year <br />P <br />0 <br />18. Trans orter 2 Acknowledgerent of Receipt of Materials <br />-Printed/Typed <br />" <br />R <br />T/ <br />Name <br />.lure <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />j <br />F <br />i <br />A <br />C <br />1 <br />L <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except <br />as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />Yeilrn:r. GENERATOR RETAINS <br />