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V State of California—Environmental Protection Agency <br /> Form Approved OMB Nor 2050-0039(Expires 9-30-99] See Instructions on back of pat"�,6. Department of Toxic Substances Control <br /> ' Please print or type. Form designed For use on efite 11 2-pikh)typr Sacramento,California <br /> UNIFORM HAZARDOUS 1. Ge erator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> isnot required by Federal low. <br /> WASTE MANIFES <br /> 1 U► C� "�' al <br /> ' 3. Generator's Name and Mailing Address tCA:State Monifest.Docurnent Number <br /> 3r1�)o S s e+ a-)Qod " B. State Generator's ID - <br /> � r <br /> ' ^ A, Generator's Phone _ <br /> (V Transporter <br /> 5. 1 Company Name 6, US EPA ID Number C. Stale Transporter's ID[Reserved.] - <br /> AMER E'AN VALLEY WA.S TE OIL C A L, 0 0 0 8 2 1 a 6 D. Transporter's Phone &0-732-4645. <br /> Q <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> QF. Transporter's Phone . <br /> 10. US EPA ID Number G..StaVoa Aty'VD 0 .. <br /> Z 63'00 CLAUS ROAD <br /> ZH. Facility's Phone <br /> p RIVERBANK, CA'4 5367 O A L 0 0 0 9 9 0 8 1 R3 �'E30 I33 018 . ' <br /> J 12. Containers 13. Total T4. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number( <br /> V No. T e Quantity Wt/Val I.'.Waste Number <br /> NON-RC:RA HAZARDOUS WASTE LIQIiIQ State- 221 <br /> * <br /> MY WATER 0 0 1 I' T 0 EPA/Other <br /> 3 GF <br /> Nb. State <br /> oD E . <br /> 4 EPA/Other <br /> V A C. State , <br /> o T ,_ <br /> ao O <br /> EPA/Other <br /> LU d. State <br /> Z <br /> Z <br /> w <br /> V EPA/Olher <br /> w <br /> J. Additional Descriptions For Materials Listed Above K.'Handling Codes For Wastes ListedAbove <br /> OILY WATER a (�1 b- <br /> LU <br /> c. d. <br /> 0 15. Special Handling Instructions and Additional Information <br /> a GLOVES <br /> Z EMERGENCY PHONE 209-6674M7 <br /> Q 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,packed, <br /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> w <br /> If I am a large quantiy generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to 6e economically <br /> n practicable and that I have selected the racticobte method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N <br /> and the environment;OR,if I am o small quantity generator,I have made a good faith effort to minimize my waste generation and sated the best waste management method that is <br /> I' available to me and that I can afford. <br /> O <br /> t } Printed/Typp�ed Name f r Signature! _>+ Month Dayf� Year <br /> j <br /> Z L+,t?y :F..+E r/ <br /> w <br /> R 17. Tr ns otter i Acknowlodgement of Receipt of Materials <br /> LLJN Pr ted/Ty ed e `;` Signature ! r.--y Month Day Year <br /> 1 w $ F r e f FM1f <br /> P <br /> ss- B '116. rans otter 2 Ac nowle eat Ricei t of Materials <br /> 71 <br /> 0 RS Printed/Typed Name Signature Month Day Year <br /> LU E <br /> v1 R <br /> ' a <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> 1 20. Facilily Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> j Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTIC 1022A[1/99( <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />