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State of California—Environmental Protechor.Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30.99) See Instructions on back of b. <br /> Please pri &type. Form designed for use on elite(12-pitch)typo—rer. I Department of Toxic Substances Control <br /> t, Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Pegs 1 Information in the shaded areas <br /> WASTE MANIFEST r (. <�� Is not required by Federal law. <br /> A O0D�O of <br /> 3. Generator's Name and Mailing Address <br /> A'y Sieh Mart f Doei7inent 144m <br /> r a L C' <br /> -a.i l a <br /> YI , <br /> A. Generator's Phone (kf`) ( )C,� � <br /> 1 �� <br /> 5. Transporter 1 Company Name 6. US EPA ID Number TFane <br /> pa rltz . + <br /> o AMERICAN VALLE=Y WASTE OIL A L 0 00 $' 2 7 I Rt, ran► i otN►' r <br /> 7. Transporter 2 Company Name 8. US EPA ID Number $M1eTrtlip p; <br /> rQ 'Ql� T'T'Tl'1 <br /> ? 1�'.'7T R 10. US EPA ID Number <br />�Z $ 00 CLAUS ROAD <br />,p RIVERBANK, CA 95347 Is L 0 0 0 1 9 0 <br />�VJ <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12 Containers 13, Total 14. Unit <br /> P (- 9 P PP� 9 <br /> JZ °' NON,-RCRA HAZARDOUS WASTE LIQUID Na Type <br /> °"°"lily WI/vel ; <br />' <br /> 3'- (OILY WATER ) 00 1 T T �} <br /> Citit+ t. <br /> o N b. "v at+ <br /> .�,. <br /> a00o E <br /> � . <br /> 00 0 <br /> R <br /> w d. Cay;, <br /> ZN <br /> w <br /> U <br /> F <br /> ZJ Additional Descriptions for Materials listed Above ' r yi•rt.v s as .,ri ' rre forwtl <br /> O OILY Wsle6lfl �tsOtY► � <br /> t t ? Il1PE"R r� � to t Handhnp <br /> d "3 <br /> N d r '.r jr'r it iCyEy 7p Y.i N + <br /> Iv 4t M• d 4� ` ; y�il r d vy�'1�� <br /> �?�tt�irkt <br /> O 15. Special Handling Instructions and Additional Information <br /> P <br /> Z <br /> GLOVE.H - <br /> Lu EMERGENCY PHONE 209-667-8857 <br /> Q16. 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 /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> IIf 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 /> Npracticable and that 1 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 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> °C available to me and that I can afford,,, <br /> O <br /> VPrint Na r) Signaretu - th D y 7 Year <br /> w T Trans porter 1 Acknowledge ant of Recei t of Materials <br /> Lu Prjpted Typed/Name f Sign rs Mont Da Year <br /> 01V I <br /> u. 0 1 Transporter 2 Acknowled ement of Rec t of Materials <br /> 0 R PrintedyP/T ad Name g Month Day Year <br /> iLu Si nature <br /> V) E <br /> R <br /> Q <br /> V 19. Discrepancy Indication Space 711l <br /> Z 1 <br /> IF ' <br /> A <br /> C <br /> L <br /> 1 20. Facility Owner or Operator Certification of recei t of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW,THIS LINE. <br /> DTSC 8022A(1/99) h t4 r <br /> EPA 8700-22 1 <br /> 1�A owy��r�GENf R}�TQR RETAINS y , <br /> 4' <br /> 1�r r9 Y yt�'s�i ter`r <br />