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to of California—Environmenta)Protection Agency <br /> -m l proved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of page 16 Department of Toxic Substances Control <br /> ase-print or type. form designed for use on elite(12-pitch)tyw- -iter. <br /> `+ Sacramento,California <br /> UNIFORM HAZARDOUS 1.•.,rotor's US EPA ID No. Manifest Document No. .2. Page 11 Information in the shaded areas <br /> WASTE MANIFEST ; 1 SPP--k19 `' of is net required by Federal law. <br /> 3. Generator's Name and Mailing Address } pK�} �} �)/ Q A. State Manifest Document Number <br /> Mo oNoa, R ^ <br /> 8. Stake Generator's ID I <br /> 4. Generator's Phon j <br /> C14 5. Transporter 1 Company Name 6. US EPA ID Number 'C. State Transporter's 0[Reserved-] d <br /> oa <br /> AMERICAN <br /> MC ICAN VALLEv WASTE OIL 0 L F i0 ? 8 D. Transport,o. <br /> r' Phone <br /> r -1646 <br /> L.0 7, Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID tReserved] <br /> F. Transporter's Phone <br /> Q <br /> 9nta> il;�rss 10. US EPA ID Number G. StatoFaci sIDy � ,I 1 <br /> i <br /> 63ffl OXALIS ROAD � <br /> F As ' r �. f FtFacility's Phone <br /> }-� 1 <br /> O ttr�._�ts:bNK �::r"s <br /> A , q,.ti30 <br /> '• 12. Containers 13, Total 14. Unit <br /> 1 11. US DOT Description[including <br /> _ Proper Shipping Name,Hazard Class,and ID Number) No. Tye Quantity Wt/vol I. Waste Number <br /> +- °. State <br /> NON-RCRA H1~ARIDOUS WASTE LI *Ifd <br /> 01LY WATER 0 4) i T 1" � 0 EPA/Other <br /> G _ <br /> oE b. Store <br /> 00 E <br /> 7 R EPA/Other <br /> Ac State } <br /> L4 T <br /> m O <br /> R .EPA/Orhe: <br /> d. State <br /> LU EPA/Other <br /> V <br /> a <br /> ° J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> r..0 <br /> OILY WATER a:" ��'�": 6 <br /> a <br /> J <br /> ,'Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> Z EMERGENCY PHONE 209-6674857 <br /> W <br /> r <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 in proper condition for transport by highway according to applicable international and nation°I government regulations. <br /> Lr if I am a Targe quonti generator,I certify that l have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> CL practicable and that 1 have selected the rracticable method of treatment,storage,or disposal currently avoilable to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,4 have made a good faith effort to minimize my waste generation and select Ike best waste management method that is <br /> available to me and that I can afford. <br /> O Printed/Typed Name . ' Signatyra <' r,.- Month Day, *Year�,.- <br /> I..e V - r .� ✓rte ek, Lt-�•M �+,r ✓ % �t <br /> W T 17. Trans orter 1 Acknowledgement of Receipt of Materials <br /> R Signature Month Da Year <br /> Printed/Typed Name /'- Ic <br /> - <br /> us / <br /> 4. <br /> W <br /> ss_ 0 18. Trans orter 2 Acknowled ement of Receipt of Materials + Manth pay Year <br /> O T Printed/Typed Name Signature <br /> � E <br /> A <br /> V19. Discrepancy Indication Space <br /> z F <br /> — A <br /> C <br /> I <br /> Ire20. FacilityOwner or O erator Certification of recei t of hazardous materials covered bthis manifest exce t as noted in Item 19, Month bay <br /> T Prinled/Typed Name �Y— <br /> T <br /> Signature <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> _ DTSC 8022A 11/991 Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />