Laserfiche WebLink
Pleese t (r tYDe. (Form desinnwf fnrnm on <br />,/ DESIGNATED FACILITY TO GENERATOR <br />' <br />1 C>arcerapf Number Form Approved. OMB No. 205M39 <br />x,. ,Foga i q(, 3 Emg 9yY Ph@Oe.::: C, Na TracYJ Number <br />UNIFORM WASTE MANIFE C A=1p <br />WA8TE'.r. = ��"'FLE <br />S a T" 4 a83 <br />Geremlo(s Namean ailingAtldress <br />GetretadaFs WwAdmss(d dteerent than matting address <br />AN AN VALLEY WASTE ON. NtIC <br />P.O BOX 340 <br />GenenstoesPhone DELM' CA 04315 20$:887-6857 ... <br />. Tnarivaner t ompany <br />AMERICAN VALLEY WASTE Oil f U.S. FPA♦10 Number <br />I.Transparkr2Cortgany Name 78 <br />s U.S. EPA ID Number <br />i <br />DK-biXOk U,S:fr IpNam.. <br />nNCNEVRON WAY <br />Faw $CASS820 TOT 888 80� C&T080012602 <br />4a <br />9. U.S. DOT Desolation (mdudag Proper Shipping Name, Haiard pass, ID Number, <br />10. Contaitkrs <br />NM <br />sort Paddng Qroup (d alry}) <br />7. <br />ItTow <br />12. Ural <br />mjvbl. <br />13, Waste Codes <br />No. <br />Type <br />14ON-RCRA HAZARDOUS WASTE LIQUID� <br />(UWOOIUMXIEDviLy'._:. <br />001 <br />T T <br />z. <br />G <br />W <br />e� <br />1, ( <br />3. <br />a. <br />1A. Spedal Nandi InsrrUNoasead Addtiorial Information <br />3LOVES <br />PROFILE * DK08OW1 <br />TRUCK, sw' <br />15. O CE F A : hereby,p,,wthataw mttwnts otitis conslArtMOM eas Poly saw aaourak:yds,nozd the <br />anOR'S/OFFEROR'S <br />marked aWye oy proper elup*g name, and are aesarieo, psc?aged <br />marked and r*aideIt+placaronteed, and are in aU respects c Amon t oN ter for titin{ auonyng to applicable Iwemabonal a not governmental regulation. If export shipment and I am Ne Primary <br />Expwbr, i xrtify that me contends W this consignment conform to the terms of me EPAAautowle"Ament <br />aleGted of n <br />I coney that me walk minimize' statement ideZed In a0 CFR 26217(a) (N I am a i" quamAy ganeretor)w (b) (N I am a quanti anent <br />e21 s n N lys re / <br />Y <br />I A. <br />7 <br />I- <br />i6. IMematianal Sttipmams 1/4 ..�/ <br />❑ Import to US. ❑ Export from U.S. <br />z <br />_ <br />PM of entrylexiC ...._. <br />Transporter eawre for exportsora . " ---- <br />.. <br />Da's"Ovl U.S. ____......_ <br />0 <br />. <br />17, Transpwler oiMa: .. ... . <br />7mnspoder t Pdn yped time Soma <br />O <br />on / 79 1 <br />I/ <br />G <br />1ianspof0�rz J1d1 sxVTypad_ ams. Signature / <br />Met Day yw- <br />t19, <br />Discrepancy <br />18a. Discrepancy lndirelion Space ❑QuanoN ! 1Type ❑Residue.. <br />❑Portal Rejection ❑ <br />Fdi Reeclien <br />186 Altemate F3atry (or Jenerator) Manifest Re(arance Nwnber <br />� <br />U.S. EPA ID Numbm <br />V <br />Q <br />LL <br />w <br />f3gllt S PICne: <br />18c. Sgnawre of giaures, Faagty, (a Oes mbar) <br />..: <br />..:...�..�,.. Monuh Day Year <br />S219. <br />Hazardous Wase Repos Merngement Meitpti Codes (j.a, codes for hazardous waste ueatment, disposal, and recyaing systems) <br />1. <br />�1411 <br />2. 3. <br />a, <br />1 20. <br />Desgnakd Fatuity Ow+mr, or Operator Cerafaaeon of mo,ptofhsraardous materials omwed by the manifest except as noted in Item lea <br />PrintedR <br />Name � ,{ SgnaiWa <br />f% /y{`.. Mona) Day Year <br />EPA FOfm <br />8700.22 {Rev,' Previous edi ons are ohsNeta 112 113 f <br />,/ DESIGNATED FACILITY TO GENERATOR <br />