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)f Cal ifornia-«Environmental Protection Agency
<br /> roved OMB No 2050-003page 9(Expires 9 30 99) See Instructions on back of a e G
<br /> int or type Form designed for use on elite 112 pitch)typewriter Department of Toxic Substances Control
<br /> Sacramento California I h.�Et k►
<br /> UNIFORM HAZARDOUS 1 Generator s US EPA Ip No Manifest Document No 2 Page 1 Information in the shaded areas
<br /> WASTE MANIFEST 0 ! PicP I (.) "— "1 1+ is not required by Federal law
<br /> Pneraior s Nome . -, of
<br /> a e and Mailing Address /�f r,L� I r` A State Mcntfest D°arvmerif"Number
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<br /> 4 Generators Phone JO�` etakT9erGeneraLor�swI`pz�^,",,' ?ar"j EIYY'�" `�-'r"'y'a!t r'�-' fi I S
<br /> 5 Transporter I Company Name 6 US EPA ID Number rCC;,Stol�eeTi'Qniportnr a IDS[ eserved]�'YrFy9iT�xFF,fi'ri
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<br /> AMERICAN VALLI Y VVA+,TE OIL A IL Ca 11110 U 2 7 7 C�p�Tr�naporters}Phone �
<br /> 7 Transporter 2 Company Name ru + »� 1s 'r '" A' w
<br /> 8 US EPA ID Number
<br /> E Stale Transparfer's 1D�Rgiarvedi]
<br /> F"Tic sparler,'s lihonay
<br /> 10 US EPA ID Number G Sat ' � m n 4 i fHAN
<br /> r ac iy IDGtA$ TP J -�,�n s
<br /> 5301) {�1./'tUS ROAD ��� �. �,
<br /> IOVE,RBANK CA' 95,367 Facdiryys Phone,
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<br /> 11 US DOT Description lmduding Proper Shipping Name,Hazard Class and 1D Number] 12 Containers l 13 Total d 14 Unit fisc lk r
<br /> No Typo—] QuantityWt/Vol f +�Josta umber!`yam�, ,.r
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<br /> Iin Canes for Wastes Elsied Aboveb
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<br /> 15 Special Handling Instructions and Additional Information
<br /> L�l.C7Vf"�
<br /> 1=MERGENO a PHONE 209-667«8857
<br /> 16 GENERATOR'S CERTIFICATION f hereby declare that the contents of this consignment are fully and accurately described above by pranoper shipping name and are classified packed
<br /> marked and labeled,and ore in all respects in proper condition for transport by highway according to applicable international d not onal government regulafions
<br /> If I am a large quamiy generator,I certify that I have a program in ploce to reduce the volume and toxicity of waste generated to the degree I have determined to be economically
<br /> practicable and that I have 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 the environment OR,if I am a small quantity 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 /> Prtnte /)yped Nama Signature Month Day` Year
<br /> ra 3 �
<br /> au
<br /> 17 Transporter 1 Acknowled e f Recei t of Materials
<br /> Prinledpod,N `a f ✓ Signaiura Montfy L,
<br /> DoyYear
<br /> 18
<br /> Transporter`C2 Acknowledgement of Receipt of Materials rJ{
<br /> Printed/Typed Nome Signature Month Day Year
<br /> 19 Discrepancy lndwotion Space
<br /> I
<br /> 20 Fault Owner or Operator Certification of receipt of hazardous materials covered b ilio manifest except as noted in Item 19 J
<br /> TYPad Name Signature Month Day Your I
<br /> 1
<br />' DO NOT WRITE BELOW THIS LINE
<br />)22A 11/9911
<br /> 22 Yellow GENERATOR RETAINS f
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