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Jan 1711 09:01a Julie Huber 209-668-3880 p.1 <br /> Please 'nt or type.{Forrn designed for use on alitaff2-pitch)ty writer,} ,; Form Approved.OMB No.2050.0039 <br /> UNIFORM NAZ.ARDOUS 1.Generator ID Nurrl6e 2 Page 1 of 3.Em Vncy Response Phone :'. 003920173 <br /> �n}}ilestTracklnB Nuaw <br /> WASTE MANIFEST C A t o V 9 �J FLE <br /> 3.Genera Nam an hla Address ji oral a to Address(11 different than moving wairesat <br /> Aa1MER1CM VALLEY WASTE O[E.INC <br /> "'.. P.O 13OX 340 <br /> Generators Phone:DEL.CA 0315 208-6$7-8857 <br /> 6.Transporter 1 pony Name U.S.EPA Q Numoer <br /> —AMERICAN VALLEY WASTE 011 CAI M118228Z8 <br /> 7•Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Pacility Name and Site Address .S,FFA ID Number <br /> DK4=ON <br /> 7300 CHEVRON WAY CA's S0012602 <br /> RIX NC <br /> FaA M20 747-89$-8C 8 . <br /> So. 9b.U.S.DOT Descripioa tme Wng Proper Shipping Name,Hazard Class,ID Number, 40.Conta nets 11.Tb;al 12.Unit <br /> FM amPsatungGroup{Hal)] No, Type Quer,* yYIM. i3.WaslaCodes <br /> Ix 1. N10"CRA HAZARDOUS WASTE LIQWD . 2211 <br /> (USED OILY WATER .` 0 0 1 T 7 <br /> z 2. I <br /> W <br /> Ult;G»;;0-has 1i t airprcPdate <br /> r:t;ic,your waste,and bas received Ot <br /> a. Y15".oLrE tti fl 15 } <br /> i <br /> 14.SpecW KardlinglnslructiensamP&iR=l110irmawn <br /> P roflle�DK 4 OIOfi87 � .. . <br /> TRUCK# " <br /> 75- CERTIFICATION: I hereby declare that d+e oonlents of this consignment are fully and accurately described above by the proper shipping name,and are dassrfed packaged, <br /> rrahed end labele&placarded;and are In all respects In proper oxrd'rion far transport aocording to appllcade interaeUmal and n4onal governmental regu4dgi s.If exportah pmentand I am 9re Primary <br /> E)Ooeter,I corny that the canlonta of Mw cslgrvrlenl conrorm to the terms of the ot%diled EPAArkrmnvredgmenl of Consent, ` <br /> I corny Vol the waste minlm star&slatenwt Iden ed In 40 CFR 26217(a)(d I am a large quanllty geanrato or(bl of I am a small quanthy pirrerator)Is true. v <br /> month <br /> Y / ,.Cp /. Y <br /> 16.lntemat awl Shiprnemtq_ ❑/import a V.S. ❑E spun Ram U.S. Port of ontryk6l; <br /> Trans ler ' rasre'1or onP : <br /> Date toawi U.S.: ' <br /> ix 17.TranW.WAdnrowledgment at Reos'pt of Nalariais <br /> Transport i PU166TypeO Name,e Stgnaw / Monti Y YOU <br /> Q Transposer 2 Pdntadr[yped Name f" lgrta on ay Year <br /> F . <br /> 1B.Disrleparrey - . <br /> 180-s]tscnaparicy Indication Space - ❑ Typ <br /> e <br /> ❑Re§due ❑Pallial Rejection ❑rulE Rejer>ion <br /> Manlfost Reference Number. <br /> M.Altemale Facility(o(Generator) U.S.EPAID NumCer <br /> t r <br /> V <br /> a . <br /> � Foci s Phhane: <br /> w 164 Signa lureefAJtemale Facility{orConeralor);; Mcnth Day Year <br /> z <br /> 19.Hazardous Waste Repos Management Me Brod Codes(i.e.,codes for hazardous waste treatment(Ilsposa(and recycling systems) <br /> a1. 2. 3:. 4. <br /> 14191 l <br /> 20.Desgnabd Faa6ty Owrer ar Operator:Cert)icatlon 0-i n ceipl d hanrdoua materials covered by the nwifesl excapl as nota m Ilam 16a <br /> Alin yped arae igzrelure Oth Day Year <br /> ,Se it c+ - 17- 130 it 0 <br /> EPA Form 6700-22(Rev,M5) Previous ditrs are obsolele, V DESIGNATED FACILITY TO GENERATOR <br />