Laserfiche WebLink
State of Cal-6rma--&mronmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Fona designed forum on elite 112 pirchf rypewrder Sacramento Calrfarriia <br /> UNIFORM HAZARDOUS 1 C'eneratars US EPA ID No Manifest Document No 2 Page 1 Information in the shaded arses <br /> { is not required by Federal low <br /> WAS'T'E MANIFEST A L 1 �� _ � of <br /> 3 Generators Name and Mailing Address -State Manifest Document Number <br /> JT (Lu <br /> 23392924 <br /> B State Generator's ID <br /> in 4 Generator's Phone p... <br /> N 5 Transporter 1 Company Name b US EPA ID Number C State Transporter s ID(Reserved] <br /> in <br /> CIO <br /> AMERICAN VALLEY WASTE OIL C A L 0 0 0 8 2 7 8 78 D Transporter's Phone <br /> 0 <br /> aD 7 Transparter 2 Company Name 8 US EPA ID Number E State Transporter s ID{Rase ] <br /> QF Transporters Phone <br /> V I I 'E�Iilile f 10 US EPA ID Number G SWo uc*y LIDO 0 0 1 9 0 8 1 6 <br /> Ctrl a 53W CLAUS ROAD <br /> z <br /> ac RIVERBANK,CA 95:367 C A L 0 0 0 ! 9 0 8 1 6 H fncila�e.Bbor 63-5181 <br /> M0 <br /> ,nz 12 Contoiners 13 Total t4 Uri <br /> V 11 US DOT Dscnppp <br /> etton{including proper Skiing Name Hazard Closs and ID Numbed Ouonhry <br /> No T Wt/Vol 1 Waits Number <br /> ? a NON-RCRA HAZARDOUS WASTE LIQUID state 221 <br /> F [OILY WATER 1 on 1 ti T � EPA/Oaher <br /> O N b State <br /> � E <br /> -W R EPA/Other <br /> A c State <br /> 8 T <br /> a° <br /> O EPA/Other <br /> -- R <br /> 93C d State <br /> EPA/Other <br /> L AtSd$setsYsl for fMIGMersafs kissed Il bow K Handling Codes for Wastes Ustod Above <br /> VILY �A <br /> -L a 6 <br /> 0 sit 7 viii <br /> LU <br /> 0 Sp.caal HandlingYlnshuchons and Additional Information <br /> o <br /> z GLOVES <br /> 1J, EMERGENCY J3H0NE 209-6617-8857 <br /> z <br /> t` <br /> 16 OI�WERATOR'S CERTIF1CJUlaF4 thereby declare tfsat the contents of Ilea const nment are fully and accurately described above by proper shipping name and are classified packed <br /> Vmat and labeled and are in all respects m proper condition for transport highway according to applicable rnternallo and nation government regulations <br /> d If I a large giwnhy generator I certify that I have a pr rain in place to reduce the volume and toxicity of waste generated to tke degree I have determined to In economically <br /> Hcable and that I#save selected the practicable method of treatment etoroge,or disposal currently available ro are which mimmues the present and future threat to human health <br /> the erwrronment OR d 1 am a small quanhty gi neraiar I hove made a good faith effort to minimae my waste generation and select the best waste management method that is <br /> eC lite to me and that I can afford <br /> 0 <br /> Printed 7iNome Signature Y _ �..., Monlh Day Year <br /> T 17 T s rter 1 Acknowledgement of Regi r of Materials <br /> ffie A Prmladl/Typed Nome Signature ` Month Day Your <br /> LU; <br /> B1 Tran ser 2 Ack of Racer f Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> W E <br /> f/7 R <br /> UF 19 Discrepancy Indication Spon <br /> A <br /> C <br /> I f <br /> L <br /> 20 F.61,11orONinivator Certification of receipt of hoxordous materials coveredby this manifest except as noted in Item 19 <br /> T Printed yped Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A 11/99) Yellow GENERATOR RETAINS <br /> EPA 8700--22 <br />