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1-ummPt <br /> proveaVMbNo.2U5 0039(Expires9-30-99) See Instructions on back of page 6: <br /> Please print or e. form designed for use on elite(12-pitch)typewriter. Department 9 Department of Toxic Substances Control <br /> i Sacramento,California <br /> L. UNIFORM HAZARDOUS 1. Generator's US EPA ID Na. Manifest Docu t Na. 2, Page 1 Informofion in the shaded areas <br /> WASTE MANIFEST . U 1 C JS= f is not required by Federal low. <br /> f U t l� of <br /> 3. Generator's Name and Mailing Address r�� A. State Manifest Document Number <br /> {J{ c.vo t 21813286 <br /> jy( M B, State Generator's ID <br /> 4. Generator's Phone lllil - �-tu-V&j C fir, f <br /> N 5. Transporter 1 Company Nome 444 6. US EPA ID Number F f C. State Transporter's ID[Reserved.[ <br /> �h <br /> 07 - <br /> o AMERICAN VALLEY WASTE OIL A 111 1101812 . ' T D. Transporter's Phone SOCI-7321-4645 <br /> CD 7. Transporter 2 Company Name <br /> tt P p Y 8. US EPA ID Number E. State Transporters ID[Reserved.] <br /> J <br /> 00 Q F. Transporter's Phone <br /> CIJU � °^�' 10. US EPA ID Number G. Stat Eac ty' ID <br /> Q " 1 �, 8fl01 90D 18 <br /> Z 5300 CLAUS'ROAD <br /> o RIVERBANK, CA 95367 A 1- e o v 1 g D H. Facility's 181 <br /> J <br /> Q 11. US DOT U Description(mcudin Proper Skipping Nome,Hazard Class,and ID Number[ 12. Containers 13. Total 14. Unit <br /> C <br /> No. Type Quantity Wt/Vol 1. Waste Number <br /> �-= a NOBS-RCRA HAZARDOUS WASTE LIQUID 221 <br /> EIWATEf2 1 T 3 [ G EPA/Other <br /> 1 0101 <br /> L00 N b. ] state <br /> co E <br /> R EPA/Other <br /> v A <br /> C. <br /> T State <br /> co O r- <br /> R I EPA/Other <br /> LU d' t .- State <br /> Z <br /> �w <br /> U <br /> EPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Of LY WATER a: Uf b. <br /> +W <br /> w <br /> a <br /> Q <br /> Z <br /> P 15. Spec-sal Handling Instructions and Additional Information <br /> iw <br /> Q GLOVES <br /> Z <br /> EMERGENCY PHONE 209-867-8557 <br /> 16. GENERATOR's CERTIFICATION: I hereby declare that the contents of This consignment are fully and occurotely described above by proper shipping name and are classified,packed, <br /> U marked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable international and nationaf government regulations. <br /> J <br /> J If I am o large qu°ntiFy generator, I certify that f have°program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that love selected the practicable method yarn <br /> 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 smaquantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O <br /> available to me and that I con afford. <br /> Printed Ty ed Name _ Si t e <br /> 9� 9 �y� r. t Month Day Year <br /> �Zcl, �� 4'1 . �{LtC;,IfStc+ IV1- ce c :� � cr4CC�; L1 'fir G �, L <br /> (}r T 17 Transporter 1 Acknowledgement of Receipt of Materials ' <br /> R <br /> uA A Pit ted/Typed Name Sign ur Month Day Year <br /> N r <br /> LU P ;� 1 Y!I C. �'�fi tJ C:yiJylat,,�, Q4.�t.,r""""'"�" •� c. <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Nome Signalure Month Day Year <br /> LU E <br /> L A <br /> 4 <br /> U - 19. Discrepancy Indication Space <br /> IF <br /> A <br /> C <br /> L <br /> I 20. Facility Ow,pewor Operator Ceriil`icatiorflofAeceipi of hazardous materials covered by this manifest except as noted in Item 19. <br /> TPrinted/Typed p'F"� /� � Signature � � Mont Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> LM <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A I1/99) (Generators who submit hazardous waste for transport out-cf-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br /> I[V <br />