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State of California-Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9.30-99) See Instructions on back of nage 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on&life(12-pis rwriter. Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest Document o. 2. Page 1 Information in the shaded areas <br /> is not required by Federal low <br /> WASTE MANIFEST ( of 1 <br /> 3. Generator's Name and Mailing Address - A. Stale Manifest Document Number 22700209 <br /> O " I'J (� I1 (I `✓ '•- B. State Generator's ID <br /> l l Gt A <br /> n4. Generator's Phone 1 1 Lt., <br /> N 5. Transporter I Company Name 6. US EPA ID Number C. Slate Transporter's ID(Reserve .I <br /> h <br /> o AMEh,�AN VALLEY WASTE OIL 111111_11111C118 2 7 f t F D. Transporter'sPhone 61.0j.732-4134L) <br /> 0 <br /> (n°p 7. Transporter 2 Company Name 8. U$EPA ID Number E. Stats Trans ortar's ID Reserved <br /> por P Y P [Reserved.) <br /> NQ F y I E Transporter's Phone <br /> CD Q Tv q??,0A?gK +m°rPCP8I 1rt_,R 10. US EPA ID Number G. StatLFoc tyvf IDD D V 1 g U 8 1 b <br /> Z 5.4DT) CLAUS ROAD 6 <br /> m H. Faciilt+s Phone <br /> NO Ii1VEi%iiANK CA95367 C A L D U O 1 H 0 1 209.8uJ13181 <br /> N U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Numbed 12. Containers 13. Total Id. UnitNo. Type Quantity WI/Vol I. Waste Number <br /> ° NON RCRA HAZARDOUS WASTE LIQUID s'°'° <br /> 3 G ( OILY WATER ) 0 U 1 I I EPA 011ier <br /> E <br /> o N b' - State <br /> m E <br /> v R EPA/other <br /> v A <br /> o T C. <br /> talo <br /> m O <br /> R EPA/Other <br /> w d. <br /> State <br /> Z <br /> w EPA/011ier <br /> U <br /> w ' <br /> J. Additional Descriptions for MaMial�Usfed Above K. Handling Codes for Wastes Listed Above ' <br /> O - OILY WAT�A - o. 0.1 b. <br /> a_ <br /> N <br /> W ry <br /> ° c. d. <br /> a <br /> Z 15. Special Handling Instructions and Additional Information <br /> Z GLOVES v( tL - t C <br /> EMERGENCY PHONC 209.667-8857 <br /> w <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipping name and are classified,packed, <br /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according to app lica6le international and national government regulations. <br /> J If I am o forge quantity generator,I certify that hove a program in place ho reduce the volume and toxicity of waste generated to the degree I have determined to be economical <br /> )yy <br /> a practicable and that I have selected thtrp rocticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heahh <br /> N and the environment;OR,if I am a small quantity generator,I have made o good faith effort to minimize my waste generation and&elect the best waste manogemenf method that is <br /> d' available to me and that I can afford. <br /> y Prinked/Typed Name Signature Month Day Year <br /> Z I J <br /> X 17. Trons rier I Acknawlad amenI of fb.ei 1 o Matariab <br /> oe <br /> w E Printed/Typed Nalme-•-�- Signature Manth �7Day Year <br /> w P <br /> O0 I8. Transporter Ac aowlad ement o Racei l of Materials <br /> Printed/Typed ed Name <br /> w I yp Signature Month Day Year <br /> N � I <br /> V19. Discrepancy Indication Space <br /> Z F <br /> _ p <br /> C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this m ifest...pt as acted in Item 19. <br /> T Printed/Typed Nam.--_? �J SignbNre Month Day Year I <br /> Y �I / r N /vim 07 41, } ..I lf", I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A(1/99) s <br /> EPA 8700-22 Green: TRANSPCiRIcI: <br />