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Stale of California—Environmental Protection Agency <br />' Form Approved DMB No 2050-0039(Expires 9 30 99) See Instructions on back OF page G. Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite(12 pitch)typ �� Saerarnenlo,California <br /> 1 tr ator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS t � is not required by Federal law <br /> WA5TE MANIFEST $ of 1 <br />' 3 fGenerotor's Name and Marking Address C �^ P <br /> pw <br /> 5. <br /> 4 Generator's Phone ! q /3 J y n <br /> I <br /> �.iW/ s <br /> RNs 5 Transporter 1 Company Name <br /> P Y b US EPA ID Number e- s <br /> co s <br /> $ AMERIC,,AN VALLEY WASTE Olt JCLA I L 10 10 1111131 21 E AM � A <br /> 7 Transporter 2 Company Name 8 US EPA ID Number <br /> a ' <br /> U 9 Desi ted Fac h Name and Site Address 14 US EPA ID Number <br /> tod Rlilept A l C)IL TRANSFER <br /> 5300 CLAUS ROAD , <br /> RWERBANK, CA 95367 ICIAIL1010101119101 4 A e , <br /> 11 US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12 Containers 13 Total 14 Unit <br /> No Type Quanta WI/Vol s , <br /> f r <br /> I a NON-•RCRA HAZARDOUS WASTE LIQUID <br /> 3 G ( OILY WATER ) C 1 T 7 G <br /> t { <br /> N b , t <br /> 60 E <br /> R <br /> a A <br /> 6 7 <br /> o O r <br /> R fr <br /> 1 sss d M <br /> LU s <br /> LLJ <br /> w <br /> 1`H �1e a r"�" 8 '"'�,��,,w''� m "svi �"+ '�~ ��k r�",� r r�� y'rk�G�' ��t�t•�n� �E a'� y* tt�,,,,Ss <br /> FA <br /> . .. -N v� �#` e4' SQL`. v7' 3a�' $. .cy. 4',. a' w' s o �x <br /> ��` �' r i�*{X �' i � a + � � � r <br /> +r :I <br /> .J aAl", <br /> " �,.�'�- peX'M ,Ft,: r�� „Ir� } <br /> 15 Special Handling Instructions and Addihonal Information <br /> Z CL OVES <br /> r <br /> EMERGENCY PHONE 209-667-8667 <br /> t•- <br /> Q16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurotely described above by proper shipping name and are classified packed, <br /> V marked,and labeled,and are m all respects in proper condition For transportby highway according to opplicable international and national government regulations <br />' If I am a large quantity generator, I certify that 1 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 anat I G <br /> y bld that selected the practicable method of treatmeMj 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 smaquantity generator,I hove made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br /> UPrinted/Tygad Nome Signature Month Day Yea <br /> w j <br /> (� 1 17 Transporter 1 Acknowled ement of Recei t of Materials <br /> R <br /> $ Pri d/T d Nama i -yam Signa f Month,, Day Year <br />' Is _? G <br /> O 0 18 Transporter 2 Acknowled amens t o Recei of~ateriola <br /> R Printed/T ed N <br /> N It Yp joma Signature Month Day Year <br /> Q R , <br /> i <br />' V F 19 Discrepancy Indication Space <br /> ? A <br /> t <br /> f <br /> 1 L <br /> f 20 Foci i Owner or O orator Certification of receipt of hazardous materials covered by this manifest except as noted in hem 19 <br /> T Printed/Typed Nome i Signature Month Day Year <br /> 7 <br />' DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A 111991 <br />' EPA 8700--22 Yellow GENERATOR RETAINS <br />