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Stole of Colifornio—Environmental Protection AgencySub <br /> - <br /> formApyrov,dOMBNo.2050-00391Eapirn 9-30991 / S¢¢ IDSffUchOnS On back r DO9¢ b. Department of Tonic vorna Contra <br /> Miami print or type,. Farm designed ler use an alit,112P rifer. 1 _ Sacramento,California <br /> I. Generators U5 EPA ID No. Manifest Document� 2. Page I Information in the skoded areas <br /> - UNIFORM HAZARDOUS of regained by Federal law, <br /> WASTE MANIFE11 ST 1017,1p: C 0 ,1 4 Jet b 14 ' ( of 1 <br /> t, Ale ilosl Document Number t> <br /> 3, Generator's Name and Mailing Address <br /> F <br /> 1xm� thy S,�xlbEa <br /> rxY7 . <br /> .. 97251.721 . <br /> C/O Regina lb y 1('-, Attrmir2y 1t �,Iv 'BI'iSbW Oetebror',s lD 1 <br /> $ v� Sox "77036R 'SrYtesto, <:'% J'53.57 v t { t•; - <br /> ,1 `A. Generator" ,1209 1 5w4-3071 � « <br /> C.ISIale T <br /> tV 3. Tronsperhr 1 Company Noma 6. US EPA ID Number rans Porter'i ID <br /> H <br /> m D,!Tromporter's Phone <br /> g ALLIED PETROLEUM CAL 0 0 0 1 1 2 3 1 4209-576-8500 <br /> m' 7. Transporter 2 Company Name 8. US EPA ID Number E State lramporper's ID <br /> F. Transporter's Phone <br /> Q G,Slot,facility,ID <br /> V 9. Designated facility Name and Sit.Add.... 10. US EPA 10 Number 1 '1 <br /> AMERICLEAN, INC. N 1D8 �2�3 �518148I31 ' <br /> J2 2570 ALMOND DR. H. Facilityv Phone <br /> r„ SILVER SPRINGS, NV 89429 INIVID1918 2 3 5 8 4 8 3 r,,,i,,'_ 702-577-9001 <br /> NO Conlainen —13 Total la. Doli i- <br /> 11. US DOT Description(including Proper Shipping Noma,Hazard Class,and ID Number) p�omn WI/Vol I. Waste Number <br /> P 9 P PP B No. Type Y <br /> C\JzState223 <br /> r.= NON RCRA HAZARDOUS WASTE LIQUID <br /> -F. EPA/Other <br /> 0"3 G T T () <br /> Slope <br /> oN <br /> b. <br /> -.m E EPA/Other <br /> .A. Slab <br /> m0 c EPA/Other <br /> R State <br /> aA <br /> f t <br /> Z EPA/Other ' <br /> V <br /> xHandling Code,for Wastes Listed Above <br /> 0 15. Special Handling Instructions and Additional Information C�/IC! (/n /'sT ILr RS-6T <br /> 16 F WEAR PROTECTIVE GEAR <br /> ( Z <br /> 24 HR FACILITY 702-577-9001 <br /> _ 24 HR GENERATOR <br /> la. GENERATOR'S CERTIFICATION: I hereby declare That the contents of this consignmeg are fully and ac to <br /> i described above l proper ono g g name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition far transport by highway according to applicable international and noliona government regulations. <br /> V <br /> IF I eve a large quantity generator,1<eHify that I hove a pr ram in place to reduce the volume and asisity of waste generated se the degree 1 have determined to be economical) <br /> C, practicable and that I have selected the practicable method of treatment,storage,or disposal currently available po me which minimizes the present ad future Threat to human heal <br /> M <br /> N and the environment;OR,it 1 am a smaquantity generator,I have made a good faith offer to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O Year <br /> Printed/�71Ped Name % Signd\re F-- <br /> LF <br /> W A I7. Trans o Acknowlad a m of Recai I of Mahrialt <br /> Month Da Year <br /> f R Primed/Typed�leRla' F Signature119/ <br /> W R C..��7� <br /> Sp Q <br /> W P <br /> w R I8, Tram anter 2 Acknowledgement of Receipt of MaterialsMonthDay Year <br /> 0 f Ninhd/Typed Nome <br /> Signature <br /> LJJ <br /> E <br /> R <br /> V19. Discrepancy Indication Space _ <br /> Z f <br /> C USED a f A11D v-)ArrZf <br /> 6 i tette noted' It.. 19. <br /> 20. Fecili Owmr or O rotor Certification of receipt of hazardo Month Day Year <br /> YPrinted/iYPd Noma �f /�� L (. 3 1�..� <br /> C DO NOTYWRIft BELOW THIS LINE. l' <br /> f Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> — (Generators who submit hazardous waste For transport out-of state, <br /> DTSC 6022A (A/971 produce completed copy Of this copy and send to DTSC within 30 days.) <br /> �' EPA B700-22 <br />