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Store-af Caifornio—Enwronmentd Protection Agency <br />Foran Appmwd OMB No. 2050-0039 (Expires 9-30-%) Sea Instructions on back oe 6. <br />Pieces prim or type. Form designed for use an elite 112-amat ftae r 9 Department! of Toxic Substances Control <br />see <br />n <br />v <br />ee C <br />01 <br />a <br />Zz <br />ses, v <br />W <br />Test F <br />Q <br />U <br />0 <br />N <br />Z <br />see <br />AL <br />oacramemo, costo va <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page Information im the shaded areas <br />WASTE MANIFEST L Q O ' / 3 S ) / is nal required by Federal law. <br />i <br />i7 of <br />3. Generator's Name and Mailing Address T I "[•. C e _ <br />,— <br />L) <br />.. G.nerator's Phone ka-1-01 6Y q9 S —fV c,c 7V C6 G% SZU i <br />5. Transporter I Company No. 6. US EPA ID Number <br />AMERICAN VALLEY WASTE OIL INC CAL 010 10181217181718 <br />7. Transporter 2 Company Name B.us EPA ID Number <br />9. Designated Facil'm�yy Noma and Site Address '10. US EPA ID Number <br />INDUSTAAIL SERVICE OIL CO IIiC <br />17ou S. SOTO ST° <br />LOS ANGELES CA 90023 71018 <br />, ICILD1019191415121 <br />11. US DOT Description (including Proper Shipping Name, Hazard Claa, and ID Number) 12. Caretakers 13. Total 14. Unit <br />No. T W Wt/Vol <br />a. <br />NON RCRA HAZARDOUS WASTE LIQUID <br />G <br />( OILY WATER) 0 <br />T T G <br />E <br />N <br />b. <br />E <br />R <br />' <br />A <br />T <br />C. <br />O <br />R <br />d. <br />15. Special Handling Instructions and Additional Information <br />GLOVES <br />EMERGENCY PHONE 209-667-6857 <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, <br />packed, mark.d, and labeled, and ore in all respects in proper condition for transport by highway according to applicable international and national gowmmem regulations. <br />If 1 am a large quantity generator, I certify that I howl a program in place to reduce the wlume and toxicity, of waste generated to the degree I have determined to be <br />econamicolly practicable and that 1 haw selected the practicable method of treatment, storage, or disposal currently owilable to me which minimizes the present and future <br />threat to human health and the envirwwsnt; OR, R 1 am a small quantity gener, r, I have made a good faith effort to minimize my waste generation and select the best <br />waste management method that is awiloble to an, and that I can afford. <br />Printed/Typed NameSignature <br />t <br />N <br />tzyr +MCAT m <br />17. Tran rter na <br />1 Ackwled <br />of Receiptof Materials- - <br />1 <br />s <br />P' /T d ,r � <br />( K !�'1' I"1�J <br />.SignaNro f - <br />rills <br />1 <br />' C/ "C <br />U <br />0 <br />1 R. Trans r 2 Acknowled ment of Receipt of Mahriah <br />T <br />Prinh d/Typed Nome <br />Sigaftne <br />Month. Day Year <br />E <br />1 <br />19. Discrepancy Indication Space <br />Is <br />A <br />C <br />k <br />1 <br />20. Fad' Owner er Operator Certificotion of receipt of hazardous motorial, covered by this manifest axce t as noted in Nem 19. <br />T <br />Prim.d/Typed Name Signature <br />Month Day',.' Yesv <br />Y <br />DO NOT WRITE BELOW THIS UNE. <br />DTSC 8022A (1/95) <br />EPA 8700-22 <br />