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State of California—Environmental Protecjtpn Agency <br /> Form Approved QMB No 2050-00391txpires 9 30 9911 See Instructions on back of page 6 Department of Toxic Substances Control <br /> Noose print or tyke form designed for use on ehto f12 p+rchj sy- mer Sacramento Colifornia <br /> ONIFORM HAZARDOUS 1 erolor s US EPA ID No Manifest Document No 2 Pogo I Information in the shaded areas <br /> WASTE MANIFESTof 7 <br /> is not required by Federal law <br /> t zfJ <br /> 3 Go.eralor's Name and Mailing Address f /y j A State Mamfost Document Number <br /> ` �1yQ�y r� X1053095 <br /> O r F,e �'ka d 11• <br /> LO r B Stals Generator s ID <br /> n 4 Generator s Phone r <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C Stale Transporter's ID(Reserve ] <br /> 6 AMERICAN VAL.LCY WASTE OIL. A L 0 O U 0 7 0 8 1 d D -Transporter'sPhone <br /> O <br /> 7 Transporter 2 Company Nome 8 US EPA ID Number E Stole.Tronsporters ID Reserved] <br /> Q I I I I I <br /> F'Transporter s Phone <br /> V 10 US EPA ID Number G Sta t,Fa +t��s 1% O 0 4 9 u 8 ' to <br /> '5300 CLAUS ROAD <br /> RIVEREJANK, CA 136367 Q O f? 1 z) 1 fi t 8 H Facility <br /> 11 US DOT Description(including Contoiners 13 Total 14 Unit <br /> Proper Shipping Nome Hazard Class,and ID Number) No Type Quantity WI/Vol I Waste Number <br /> NOM-RCHA 14AZ-ARDOUS< WASTE: LIQUID State 2: I <br /> ( OILY WATER ) A 0 1 1 T t � � EPA/Other <br /> N l <br /> E b State <br /> N <br /> ao E <br /> R EPA/01her <br /> A <br /> T c State <br /> O <br /> R EPA/Other <br /> d State <br /> EPA/01her <br /> W <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> OILY WATER xs a p# b <br /> W t`� <br /> c d <br /> J <br /> 15 Special Handling Instructions and Additional Information y <br /> Q GLOVES <br /> Z CNICROENCY PHONE 20"61-8857 <br /> 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 /> Vmarked and labeled and are in all respects to proper condition for transport by highway according to applicabla international and national government regulations <br /> If I am a large quantity 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 be economically <br /> practicable and that I hove selected the practicable method of treatment storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and Ike environment OR if I am a smaquantity generator,I hove made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> ne available to me and that I can afford <br /> O <br /> jr:nte Typed Na Signotu Mont Do Yeas <br /> Irl a� f ,� 4 b <br /> A 17 Transporter I Acknowled ement' Receipt of Materials <br /> ru�ed/,Ty ad N rie Signet �Qont Da Year <br /> N 1!(�J tl fj <br /> S <br /> 0 18 Trans iter 2 Acknowlecligament of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> LLJ E <br /> R <br /> F 19 Discrepancy Ind icalion Space <br /> A <br /> C <br /> I <br /> 1C <br /> 1 20 Facility Owner or Operator Certification of rece+ t of hazardous materials covered by this manifest except as noted in Item 19 <br /> 0 4 <br /> Printed/Typed Name Signature Month Day Year <br /> 0 <br />' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A 11/99] <br />'PA 8700-22 Yello, GENERATOR RETAV5 <br />