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Stale o1 Protection Agency <br />Form Approved OMA No. 2050-0039 (Expires 9.30-991 Y Site Instructions on back o.,J9e 6. Department of Toxic Substances Conmel <br />' Please print or type. Form derfgned for use on elite (12-pikhl rypewrirec <br />Sacramento, California <br />UNItQAZARDOUS <br />Generalor's US EPA ID No. Manifest Docomenl No. <br />2. Page 1 <br />Information in the shaded are., <br />WA'S MANIFEST16A(40410-W331 <br />I <br />a n <br />u not required by Federal law. <br />3. Generator', Name and Mulling Address <br />541,��{Qn.+eywx+�i�s <br />A, Stott Manifest Document Number 996415429 <br />nJ <br />xl A-, /'s poA;- 12o ' <br />B. State GenerI I ID <br />h <br />10 <br />�4�7ee �9 <br />{, Generator3 Phone [ �u-e r. ,� �'t �' 3 3 L <br />�" 1 <br />N <br />5. Transporter 1 Company Name b. US EPA ID Number <br />C Stab Tmoxporte: a ID [Reserved.] <br />bo <br />o <br />tC <br />1AERICAN VALLEY WASTC OIL A L 0 a fl 8 z T T 8 <br />D. Transporter's Phone 800 T32 46+3 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter', ID [Reserved.] <br />cyQ�V <br />F. Transporter', Phone <br />lJ <br />viAMEHICLEAN <br />9. Dmigmated Facility Name and Site Address 10. US EPA ID Number <br />INC <br />G. Stat, Facility', ID <br />LOZ4M) <br />N I V 11121816111141 3 <br />ALMOND DR <br />H. Facility, Phone <br />�0 <br />ILVERSPRINGS NV 89429 IN IV 10 19 18 12 13 15 1814 FA <br />7w2_577*CK)i <br />�U12 <br />11. US DOT DescripiloA including Proper Shipping Nome, Hazard Class, and ID Number) <br />. Cenloinen <br />13. Total <br />1/. Unit <br />Ne, <br />T <br />Ouonli <br />WI/Vol <br />I. Waste Number <br />F <br />I <br />a NOM-RCRA HAZAROOUS WASTE LIQ[ 110 <br />style 221 <br />f USED OIL) <br />0 01 <br />T T <br />G <br />EPA/Other <br />`•r0 <br />N <br />b. <br />State <br />m <br />E <br />EPA/Other <br />� <br />II <br />a <br />A <br />6 <br />T <br />a <br />state <br />m <br />0 <br />EPA/Other <br />_ <br />R <br />ae <br />F <br />a <br />State <br />Z <br />tW <br />EPA/Other <br />W <br />J. Additional Descril5ridn, Ior Materials Listed Above <br />Handlidtf Cade, for Wastes listed Above <br />USED OIL & WAiEIt <br />a; p1 b. <br />W <br />K <br />' Z <br />15. Special Handling Inslrvclion, and Additional Information <br />Z <br />Z <br />GLOVES <br />EMERGENCY PHONE 209-667.8167 <br />_ <br />lo. GENEf001111 CERTIFICATION! [hereby declare that the contents of this conienthenl are fully and accorotelY described above by proper shipring dame and are classified, packed, <br />marked, and labeled, and are in all respecb in proper condition for transport by highway according to applicable international and nalionaPgovernment regulations. <br />r <br />hon <br />1hm I hove a pragtre in place ro reduce the vel •me and toxicityvf wmb g e olein ro the degree I have dfutur i thr to be economically <br />quantity general." I the <br />I havd ,elected the ymB achy method r, heals storage, or currently azo tole the wad future <br />If 1 c ar.ti <br />to method healthand <br />me which miand <br />de <br />6that ses <br />ith effol <br />ma st a bestt <br />am a smallquantity generofoq I hove made a good faith erfart to m n mlxe my wo,te generation oad select the best wmn management method that is <br />genie <br />Imiand; <br />of iifI <br />and that l can afford. <br />,dN <br />Z <br />PrP„ me <br />Signature % <br />�Akonjl"� Day/ <br />1i`11— <br />; <br />r <br />V <br />R17. <br />-Transporter 1 Ackn wled emenl of Receipt of Materials <br />& <br />A <br />Pri yp di ams � <br />,$ign, n <br />/Ijetn Day/ ]'}flyer <br />C �� ^Kej <br />six <br />w <br />YQ <br />p <br />18. Transporter 2 Ackrlowled ement of Receipt of Materials <br />AT <br />Prinrod/Typed Nome <br />Signature <br />Month Day Year <br />1sga� <br />R <br />U <br />19. DlscHponty Indication Space <br />y <br />—. <br />P <br />A <br />C <br />I <br />L' <br />I <br />20. Faeili Owner or O rarer Certification a reed t of hazardous malerlals <br />severed 6 this ma ifetl exec 1 as noted In item 19 <br />_ <br />j <br />Pdnled/Typed Name <br />Signature <br />Month Day Year <br />Y <br />3 <br />1 <br />DO NOT WRITE BELOW THIS LINE. �{{f <br />Yellow: GENERATOR RETAINS 9 <br />