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State of California—Health and Welfare Agency ` <br /> Form Approved OMB No.2050--0039(Expires 9-30-91' Department of Health Services <br /> Please print or type. (Form designed for use on elite itch typewriter). Toxic Substances Control Division <br /> �// Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 <br /> WASTE MANIFEST Document No. Information in the shaded areas <br /> n In In 1 11 of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address A. State Manife tFT <br /> c e m er <br /> B. State Generator's ID <br /> 4. Generator's Phone <br /> U) 5. Transporter 1 Company Name 8. US EPA ID Number C. State Transporter's ID <br /> D ftvironmental Services, Inc D 9 8 $ 4 f> 8 1 6 3 Transporter's Phone <br /> a D. Trane o 415-732.4444 <br /> 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 /> IQ Hedrick Diaayee Oil Co. <br /> tt./3fdit IA ID 10.18 18 le 13 16 12 2 12 <br /> !0 210 Bncinal at., S4nta Cz-,=, CA 95Q68 H. Facility's Phone <br /> IZ IC tL ID 10 18 IS 18 3 8 2 2 2 408-427-3773 <br /> l¢ <br /> 012. Containers 13. Total 14. I. <br /> ILL 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste Na. <br /> l aNo. Type <br /> a <br /> V Wt/Vol <br /> ►Z G Waste Flammable Liquid, A.O.S. State <br /> 134 <br /> E Y'l abl,e Liqufd, U 1993 EPA/Other <br /> E b. 042D m ,o0100 0 <br /> o <br /> R State <br /> A <br /> T <br /> O EPA/Other <br /> o R c, <br /> o State <br /> 0 <br /> M <br /> EPA "'her <br /> 2 <br /> Lu d. <br /> H <br /> Z State <br /> w <br /> U EPA/Other <br /> LU <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> wRinne ',rater from cleaning underground fuel tank a. Ol b <br /> tgasalisie} C. d. <br /> J <br /> ZWater 954, gasolene 5*t <br /> Q 15. Special Handling instructions and Additional Information <br /> Z <br /> = Avoid contact with Skin, wear glovoe <br /> J <br /> J <br /> Q 18. <br /> U <br /> JGENERATOR'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 /> (L national government regulations. <br /> U) <br /> X 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 I have determined <br /> O 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,it I am a small quantity generator,1 have made a good faith effort to minimize my waste <br /> V generation and select the best waste management method that is available to me and that I can afford. <br /> Z <br /> w Printed/Typed Name Month Day Year <br /> c7 Signature <br /> w <br /> WR 17. Transporter t Acknowledgement of Receipt of Materials <br /> G A Printed/Typed Name <br /> N r Signature .1 Month Day Year <br /> i <br /> -r' ._. jai •-1 <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> U) <br /> Q R Printed/Typed Name Signature <br /> Month Day Year <br /> O E <br /> Z <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <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 <br /> Month Day Year <br /> DHS 8022 A(1188) <br /> EPA 0700700-22 Do Not Write Below This line YELLOW: GENERATOR RETAINS <br /> (Rev.p-gg)Previous editions are obaolet.. <br />