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State of California—Environmental Protection Agency <br />' Farm Approved OMB No 2050-0039{Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on ehle f 12 pilchi writer Sacramento California <br /> UNIFORM HAZARDOUS onerator s US EPA ID No Manifest Document N 2 Page I Information in the shaded areas <br /> L <br /> -s l 1 is not required by Federal low <br /> WASTE MANIFEST r. of <br /> I 1, F3 <br /> Generotor s Name and Mailing Address l `/s �o �p Y A State Manifest Document Number 21142788 w 1 w ^7 8 8 <br /> 4W4 �.� 6l �o� �ii 6Jrfir 4L }V( <br /> 1 y � 8 State Generators ID <br />'^ 4 Generator s Phone Ur7` r-f�1 ��I j -d 1 `�j��i ��_ ('Lr i L t`j <br /> N C 5 Transporter I Company Name 6 US EPA ID Number State Transporter s ID[Reserved] <br /> srf <br /> C) ,[[AFRICAN VALLEY WA1Z E OIL A L 0 0 0, 6 � / is � �� D Transporters Phone 600- -464 <br /> 0 <br /> ao <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID(Reserved] <br /> VF Transporter s Phone <br /> A eWV.tdeA*We and Site Address 10 US EPA ID Number G c7 <br /> 5 Sto9a%stydD9 8 2 3 6 4 Q 3 <br /> z430 ALMOND DR IF��FF Y moi•■ d <br /> hone <br /> O_ H Facility s <br /> ILVERSPRiNGS. NV 89429 r } � � � „) 702- <br /> 577-9031 <br /> < 12 Containers 13 Total IA tin t <br />'U 11 US DOT Description(including Proper Shipping Name Hazard Glass and ID Number) <br /> Na Type Quantity Wt/Vol I Waste Number <br /> z a NON-RCH A HACZAF�i�t�i.i:, WA�1 F- Ll QUtE� State <br /> i <br /> G ( 01LY WATER ) -I <br /> `, r O EPA/Other <br /> E b I V <br /> 4 N State <br /> co E <br /> R EPA/Other <br />'v A <br /> a <br /> T ` Stare <br /> Q <br /> DO <br /> R EPA/Other <br />' d ur <br /> LU <br /> Srafe <br /> Z <br /> w <br /> (} EPA/Other <br /> w <br /> 1 Additional Descriptions for Moterrals Listed Above K Handling Codes for Wastes Listed Above <br /> OILY WATER a CI-1 6 <br /> LU <br /> LU <br /> c d <br /> Z 15 Special Handling instructions and Additional Information <br /> a GLOVES <br />'z EMERGENCY PHONE 209-667-885 7 � <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accuraieky described above 6y propershipping name and are classified packed <br /> Q marked and labeled and are in all respects in proper condition for tronspoo by highway according to applicable international end notional government regulations <br /> If I am a large quanliy generator 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be economicci <br /> � practicable and that I Gave selected therochca6le method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment OR if I am a small quantity generator I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> cif <br /> O available to me and that I can afford <br /> A it <br /> Holed(Typed Na e ! Si f re f v Manthi D Yeor <br /> Lw T <br /> 1 P lrC� (�3� v, <br /> Ur R 17 Transporter 3 Acknowledgement of Receipt of Materials <br /> cle <br /> A r193 ed/Typed Na a Srap of re ant a Year <br /> P ' <br /> T ff h� Y <br /> O 0 18 Trons orter 2 Acknowledgement of Receipt of Materials <br /> R <br /> Printed/Typed Nome Signature Month Day Year <br /> LU E <br /> R <br /> 19 Discrepancy indication Space <br /> F <br /> A <br /> C <br /> I <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> 1 Print d/Typed Name Signature Month=D.yY..r,f( <br /> DO NOT WRITE BELbW THIS LINE <br /> Orr '0 Crf EP-Tok VIFlttN 3 D_. S <br /> DTSC 8022A It/99) - as s c N„rr c,i o ,iw, <br />'EPA 6700-22 "� <br /> FTIC im <br />