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State of California—Environmental Protection Agency <br /> Form Approved OMS No.2050-00391Ezpires9-30-99) See Instructions on bock of page 6. Department of Toxic Substances Control <br /> Please print or type. Form designed For use on elite(12-pikh)typewriter. Sacramento,California - <br /> UNIFORM HAZARDOUS ^otor's US EPA ID No. Manifest Document Nu 2. Page 1 No an ion in the shaded areas <br /> WASTE MANIFEST y\ not required by Federal law. <br /> C1 1761 q 121C of 1 r.�(/r�^s <br /> 3. Gen era tori Nome and Mailing Address /t j ,� � o� J'lsr. y m t 4 A. State Manifest Document Number /re 33 9 223 V <br /> O 345 f�, t L 1 L��."r�� U,'VO B. Stale Generator's ID L <br /> A `i <br /> h <br /> A. Generators Phone 4^U <br /> n vs <br /> N <br /> S. Transporter I Company Name 6. US EPA ID Number C. Stale Transporters ID Reserved.] <br /> h <br /> as AMERICAN VALLEY WASTE OIL A I L I 111111111171817 D. Transporters Phone J <br /> 0 <br /> 0 <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporter's ID fReseryed.1 <br /> QF. Transporter'.Phan. <br /> :V fta 0fi&"" 0*Le 10. US EPA ID Number G. stet6JacAty'.ID0 0 0 1 9 0 8 1 6 <br /> tUa 5300 CLAUS ROAD <br /> COO RIVERBANK, CA 95337 CAL 0 0 0 1 9 0 8 1 6 H. Facil <br /> (a�0 'y66%b"181 <br /> Q 11. US DOT Description(including Proper Shipping Nanta,Hazard Class,and ID Numbed 12. Containers 13. Total 14. Unit <br /> (.q V No. Type Quantity WI/Vol I. Waste Number <br /> Z a. NON-RCRA HAZARDOUS WASTE LIQUID state 221 <br /> _ (OILY WATER) 00 1 T T G <br /> 3 G f EPA/Other - <br /> o N b. �J State <br /> E <br /> R EPA/Ods.r <br /> ar A <br /> tere <br /> o T S <br /> R EPA/Olher <br /> — R <br /> z <br /> � d. Smle <br /> Z <br /> W <br /> U EPA/Other <br /> w <br /> J. Additional D.scri lions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> Z 51LY WATER 01 b. <br /> W <br /> d <br /> Z <br /> Z 15. Special Handling Instructions and Additional Information s l <br /> GLOVES s l y33 N , I�ccl�lso :,. w <br /> Z EMERGENCY PHONE 209-667$857 1 �J � Slx K�N t" J�} 175;(Js <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the c.rt"oft consignment are fully End accurafaly described above by proper shipping name and are classified,packed,. <br /> Vmarked,and labeled,and are in all respects in proper condition br transport by higlswaysotcarding ro applicable international and notional government regulatl66.; <br /> J If I am a large quantiq generator,I certify that I have a proggram in plaU to iAuce the volume and toxicity of waste generated to-the degree I have determined to be ecanamically <br /> hpracticable and that I have selected the practicable method aF treatment,stbrage,or disposal currently available to me vbicfrmimnpzes the present and Future threat to human health <br /> and the environment;OR,if I an is small quantity generator,I limy dude a good faith effort to minimize my waste+generafion anfi select the best waste management method that is <br /> d' available to me and that I can afford. <br /> y Printed/ y d Name Signature j. Month Day Year ' <br /> W T 17'Tram orter I Acknowledgement of Ri!4 t of Materials �• ° r/ <br /> R <br /> sty A Prin /Typ j me ���' ignatur ! I /� // T Month Day Year <br /> NS W 0 Ie. Trans Her2Acknowe ement oMcei f Materials " <br /> Q R <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> Q R <br /> CJ 19. DiscrepancyIndication Space <br /> Z F <br /> — A <br /> C <br /> 1 <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 Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />