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Dec 10 1511:46a American Valli—Waste Oil 2r,-668-3880 p.2 <br /> Please print or type.(Form deli nal for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generalor lD N'unber 2.Page 1 of 3.Emagency Response Phone 4.Manifest Tracking Number q p <br /> WASTE ttMMIFEST LWL iK1�8 z,iTf1� �CfM9 .7�3l4 1 GD F, <br /> 5.Generalves Name and Mailing Address Generalors S'de Address(if different herr railing address) <br /> CI IY QF`.T'X CX.t4 <br /> ill?D EJ4t`3 1 tMAIN`;'11 <br /> i10,`. KIC7id,CA ' 1vr <br /> "r.9 U3r X3`,'4 <br /> Generators Phone: - <br /> L Transporter 1 Company Name U.S_EPA ID tNmlbef <br /> �.+�MEli1"AN VALLtz'I VIJA Af O{i.,iris; f:AL'.fJ0P42ifi74 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> f_fr.1 ;u!:1re rvA #;f i-;9- 1..r' <br /> 8.Designated Facltty Name and Site AddressU.S.EPA ID Number <br /> <'{W1 L`�7'lIt!{�y`1:t�'141ii�ditlrt•.!'1"i�:.iGltsiflf t:f• ii{'_>.f/�iLA.l_i.C: <br /> Facility's Phone: :: �7a17r3Lh <br /> ga, 9b.LS.DOT Description(including PreperShipptry Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit � <br /> HM and Paciing Group(If any)) No. Type Quantity VYf.No',. 13.Wash(odes <br /> K 1 <br /> d " <br /> 2. 'uu <br /> CD I <br /> h <br /> it i <br /> 3 " <br /> i <br /> l <br /> i <br /> ENV ROI ME Teti <br /> 14.Special Handling Instructions and Additional Information HFAITIJ n Wo—ler-c <br /> N4�1'3y}Gi.fel::-sd:iKi-i.ii,A8;�1•��t::2�i'i;i,i..�ii..�l:ii_.ii:i. i;{:<.air-t; <br /> C.Cti!T.kt;T.c3-iNtLA 11AR[3Y <br /> 15. GENERAYOR'StOFFEROR'S CERTIFICATION: I hereby declare tha'the oonterts of this conslgrhment are fully and accurately described above by the proper shipping name,and are classifid,packaged. <br /> marked and fabetediplacarded,and are in all respects in proper condbon for Wisport according to applicable intemalioma and national govemman al reyedations If export shipnent and I am the Primary <br /> Exporter,I cerUfy that the contents cl ft consigTnaA conform to the tams of the attached FPAAckra%iedgmonl of Consent. <br /> I cw*that fne waste rnvnirization statement identiied in 40 CFR 26227(a)(d I am a large quantity generalm)or(b)(ifi am a small quantify gaterafor)is true. <br /> Generatnrsl s Pdntedriyped Narirefftt Signaiv r Month. Day Year <br /> V 12 <br /> ri 16.Inemational pmints <br /> mwrt%U.S. ❑Ewt ton,U.S. Port 01 enhyfevit _ <br /> 2 <br /> Transporter signature(for exports only): .--Dade leaving U.S- <br /> 17.Tran spotter AckniNMdgrnent of Rsoeipl of Materials <br /> Uj <br /> Trarspaxer 1 PnnteWVed Nance f / -S g�alure'�/ T�r --Mentth---.Day year <br /> r' }' �,. %�� � .- --. '— '4 <br /> QTan ZPdntedrr NUme ff / f' Signature'" Month Day Y&r <br /> 1 B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Mantles:Reference Number,. <br /> 180.Alternate Facility(or Genera" U.S.EPA ID Number <br /> V <br /> Facility's Phone. Month Day Year <br /> 18r Signalum of Aitemate Facility(or Gererator) <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes lcr hazardous waste beabnenf,disposal,and recycling systems) <br /> 0 1 Z 3 4. <br /> 2A Desfgnated Faci:ty Owner or Operator.Cedificafien of receipt of hazardous materials covered try the mar W except as noted in Item 1 Ba <br /> Pnntedtryped Name Signature Month Day Year <br /> IPA Form 8700.22,Rev.3-05) Previous editions are obsolete <br /> TRANSPORTSR'S COPY <br />