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State of California—Environmental Protection Agency a b. <br /> Form Approved OMS No.2050-0039(Exp in.'9-30-991 See Instructions on back to 9 Department of Toxic Substances Control <br /> Pleom print or type. Form designed for use oa elite(12-pits, ewriMr. �,. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. page 1Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST Y cL c 7 0 5^ 9 7C of 1 <br /> 3. Generator's Name and Mailing Address s^ A- State Manifest Document Number <br /> sere' R k," �t 23392871 <br /> r <br /> S. Sbb Generator's 10 <br /> 0 <br /> sij A. Generator's Phone pp 41- -,q <br /> H 5. Transporter I Company Name6. UB EPA ID Number C. State Transporters IDRf eserved.] <br /> sn <br /> o AMERICAN VALLEY WASTE OIL iC,A L 0 0 0 8 2 7 a 7 a D. Transparner's Phone 800-732'4645 <br /> o ^ <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. StateTramporler's ID Reserved.] <br /> F. Transporters Phone <br /> COU TV"Cn t'JSr Tt PER 10. US EPA ID Number G. StotL{ac yr'IIDO 00 1 9 08 1 s <br /> y <br /> a 5300 CLAUS ROAQiTR7V3 H. Facility's Phone <br /> M0 RIVERBANK,CA 95387 C I A L 010 10 111910181 116 209-883.8181 <br /> 12. Containers 13. Total 14. Unit <br /> U 77. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No---T— <br /> Type Quantity Wt/Vol I. Waste Number <br /> Z a. NON-RCRA HAZARCOUS WASTE LIQUID State 221 <br /> 3 c (OILY WATER) 00 1 T T Q G EPA/Other <br /> Em Stone N b. ' <br /> oo E EPA/Other , <br /> n R <br /> < A a Swiss <br /> o T <br /> m O EPA/ath.. <br /> R <br /> w d. State <br /> Z <br /> W EPA/Other <br /> U <br /> W <br /> J. Additional Descriptions for Materials Listed Above K, Handling Codes For Wastes Listed ATfovs <br /> Z OILY WATER 01 b, <br /> NAN <br /> w <br /> � <br /> C. d. -411111111111111 <br /> J <br /> 0 Z <br /> 15. Special Handling Instructions and Additional Information tGI <br /> a GLOVES <br /> Z EMERGENCY PHONE 209.8875857 ? �I F Ca q° -Lltn <br /> x <br /> 16. GENERATOR'S CERTIFICATION: therabydeclarethottheconronbofthisconsigrent are fully and accurahaly described above by proper shipping name and are classified,pocked, <br /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If 1 am a Targe quantity generator,I certify that I have a pr ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economi <br /> a practicable and that U.selected the practicable method of treatment,storage,or disposal currently ovailable to me which minimizes the present and Future threat to human heahhcaAt' <br /> H 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 dsatis <br /> oc available to me and that I can afford. <br /> 0 _ <br /> r Printed/Typed / /p rsC r/ Signature r l _ Month Days O <br /> W T 17, Tronsportew I Acknowlec ement of Receipt of Materials <br /> A <br /> W A Printed/Typed Name �r Signature Mond: D Year <br /> w s .'tc X-v— C S o <br /> W 0 18. Tram rter 2 Acknowled ement of Recei t of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> w E <br /> Q R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Nome Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A I1/991 Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />