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State of California—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039{Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite(12 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> / r ! G' is not required by Federal law <br /> WASTE MANIFEST <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number "� <br /> 2.1.806544 <br /> B State Generator's ID <br /> LO <br /> 4 Generators Phone <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter's ID[Reserved] <br /> LO <br /> co <br /> o ArviEfflCAN VALLEY 01ASTC (ill. A L r) 0 a 8 2 7 fT £, D Transporters Phone $400 732-4646 <br /> 00 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved I <br /> QF Transporter's Phone <br /> V Mto e S A e 10 US EPA ID Number G SiatdocAoyCDO <br /> Z 5'1100 CLAUS ROAD H FacilePhone <br /> y o i;IVEwRE1ANK CA 95,367 ft Li 010 C+1119 1 I1) <br /> Q 12 Containers 13 Total T4 Unit <br /> U <br /> 11 US DOT Description(including proper Shipping Name Hazard Class and ID Number) No Tye Quantity wi/Vol I Waste Number <br /> a NON-RCRA HAZARDOUS WASTE LIQUID State ry? ! <br /> 3 Ca O1L.Y WA TLPk } 0 4 1 T T t � r f G EPA/Ocher <br /> 1 <br /> o N b stare <br /> oo E <br /> v R EPA/Other <br /> v A <br /> Tc state <br /> ccooO <br /> R EPA/Other <br /> LU d <br /> H State <br /> Z <br /> w <br /> V EPA/Other <br /> ILLS <br /> J Additional Descnptio`ns For Materials Listed Above K Handling Codes Far wastes Listed Above <br /> 01 OILY WATER p 3 b <br /> LULU <br /> � c d <br /> J <br /> Q <br /> Z <br /> O 15 Special Handling Instructions and Additional Informahon <br /> P <br /> GLOVES <br /> LU EMERGENCY PHONE 209-667-8857 <br /> r <br /> 16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of this const nment are fully and accurately described above by proper shipping name and ore classified packed <br /> Umarked and labeled and are to all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> IF I am a large quantity generator I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economtcall <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 /> rn and the environment OR el"I am a small quantity generator I have made a good Faith a ort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br /> O <br /> >- PnntedATyped Name " +` Signature �/` 1 onrh Day Ygar y <br /> R17 Transporter 1 Acknowled ement of Receipt of Motertals <br /> °C M Printed/Typed Noma T <br /> tgnature Month Day Year <br /> LU R /A _ ", . r f t <br /> s �r , f L_ . <br /> w 0T 8 Transporter 2 Acknowled ement of Receipt of Materials <br /> 0 i Printed/Typed Name Signature Month Day Year <br /> w E <br /> � R <br /> v19 Discrepancy Indication Space <br /> z F <br /> A <br /> C <br /> I <br /> L <br /> t 20 Facile Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> IRPrinted/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> DT5C 8022A )1/99) <br /> EPA 8700-22 YLEIOw GENERATOR RETAINS <br />