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Please print or type.(Form designed it use on'blite(12-pitch)typewriter.) y Y Form Approved.OMB No.2050-0039 <br /> Idr D Number 2.Pagel. 3.Emergency Response Phone 4 Manifest TrackingNumber <br /> lJpWASTE HAZARDOUS n J� `/` p'�r' r 9 n� spon fl <br /> WASTE MANIFEST 1 / - QJy+ r V FLE <br /> 5.Generators Name and Mailing Address y`l � 4ua o 1n,rnM:oU <br /> yrne r6witGenerators rens it i eren than mailing address) <br /> r/I L, <br /> Genera Pl;.—" 1- •[.7/l:~C(1 C i;:16n�t ix>,,.u3 rr..h:x3•,.:� ,,.•, .. ,.. <br /> 6.Transporter f niWp—arry Name, .•+c.:, yr o n..✓a ,. •.. . . U.S.EPA ID Number <br /> la 21s':,;ytrdlTt•dy%iJ"L Say:_� ,. <br /> AMERICAN VALLEY WASTE OIL , <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Des,gnated Facility Name and Site Address U.S.EPA ID Number <br /> RNERBANK OIL TRANSFER <br /> 5300 CLAUS ROAD CAL000190816 <br /> RIVERBANK, 0185387 209,E383.131,81 , t <br /> Faday s Phone. ledT ^.a6v 1218 trill 10116nt'd fN ulzr.'•. <br /> 9a 9b U.S.DOT (u,dudi Shipping Name,Hazard"Class,ID,tyjtSlgrTt o1zUa its 6U)llCnO,E: •:.^10,-Containers 11:Total 12.Ural <br /> HAI' and Packsg G4p( y)) No. Type Quantity WL.Nol. 13 Waste Codes <br /> L - I. .7ati.tn6ti 0;103130 0410 nBflud;Q S1dw.3m Er ;y,.J',, ' <br /> N0NACRA HAZARbo' us WASTE DQUIO •'ylmlto <br /> o -- <br /> MEU OILY WATER r ((�� \ <br /> 1lzyitllid2nl� r1VGm i"nc,r.Y:.4 �Y..T .�(,,lt,> G <br /> z 2 J+,cnylnl brU ni no ION ta)le U1?91111,LLJ <br /> 3 <br /> 4 <br /> 14 Speoal Handling Instructions and Additional Information <br /> GLOVES <br /> J - <br /> 15 GENERATOR'S)OFFEROR'S CERTIFICATION: I hereby declare Uriat the contents of this coni nvhenl are fully and accurately described above by the proper shipping name,and are dassrW.pacl:agec <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport ecwrding to applicable international and national governmental regulations If export shipment and I am Ne Primary <br /> Ex,oner,I cerofy that the contents of this Consignment conform to the terms of the attached EPAAdvIeWedgmenl of Consent. <br /> I certify tha:the waste minimization statement identified In 40 CFR 26227(a)(if 1 am a large quantity generator)or(b)(if I am a smau quanuty generator)is we. <br /> Generators/l Printed/Typed Narne bignalure onth Day Year <br /> 16.International Shipments <br /> F– ❑Impon to U S ❑Export from U.S Pon of entrylexit <br /> Transporter signatire(for exports only) Dale leaving U.S ' <br /> w 17.Trarssport&Aduwwledgmenl of Recaipt of Matagats <br /> Transporter 1 PninteNTyped Name Sinature Month ay ea' <br /> fY <br /> z Transporter 2 PmtedrTyped Name 5ignature r� ay Year <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space Quanb <br /> ty ,' Type ❑Residue ❑Partial Rejection ❑Full Refection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(a Generator) U.S.EPA ID Number <br /> J <br /> Q <br /> ILL Facility's Phone: <br /> w 18c Signature of Alternate Facility(or Generator] Month Day Year <br /> N <br /> a <br /> z <br /> N <br /> 19 Ha2ardous Waste Report Management Method Codes(i.e,codes lir hazardous waste treatment disposal,and recycling systems) <br /> w 1 <br /> 0 . 2 3. 4 <br /> 20.Designated Fadrty Ovmer or Operator:Certification of MWO of hazar9ous materials covered by the manifest except as noted In Item 18a <br /> Prnted/TypedName j I !', Signaue �- Month Day Year, <br /> EPA Form 870O-22(Rev 3-05) Previous editions are obsolete. TRANSPORTER'SCOPY <br />