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lboow I � 41 o Please print or type. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAI_N361443 I 92b-4d,--?V•j� 'n G BF 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) QAiar-c',RW F�ARK;i,C.AFtNI--i Ly k-- 5M.,f::A�T 15759 TELSA RD I 8OW CORRAL F§C)E.:I_('+W R0 Generators Phone;"' t_ V .R[W 1jR iK •0A 94,550i-TRACY.C A fl ;?7fi 6.Transporter 1 Company fVame U.S.EPA ID Number rpt F.RICAN VALLEY VVA61L=OIL, %K- CAROCIU272 7.Transporter 2 Company Name U.S.EPA ID Number lyit;1#tE I3FPJIUC;REC(.iVl-RY SYS'fC:.l1dS IW, CAROMI175t;,y2 9.Designated Facility Name and Site Address U.S.EPA ID Number Y#.IMA YES LLL 2TIWIC. #:f?'bi;T A7R43f 015I-W4 ,'i.+r�M,roc. 1�F.YLY.a Facility's Phone•4 ga. 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quantity Wl.Nol. h6(*N Rf RA VtdP2-Sqf S01 10,Aii°:t3 tF3F7iF`�,�kal. JAI !:6 ' "Im 'P u� rz 2. 3. 4. 14.Special Handling Instructions and Additional Information t'KCA,ILL F�f9S�1ItF',kI�II.SFi1. tF2G91l1 EJ%1EK(4l:.yk, 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.€f export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)oi(b)(ifI am a small quantity generator)is true. GeneratoeslOfferors Printed/Typed Name Signature Month Day Year -j 16.International Shipments f-,- ❑Import to U.S. ❑Export from U.S. Part of entryle>ut; z Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment ofReceipt ofMaterialsLLI fy Transporter 1 Printedffyped Name Signature " Month Day _ Year zTransporter 2PrintedffypedName Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Ouanli ❑ ❑ ❑Full Rejection ty Typo Residue Partial Rejection } Manifest Reference Number: 186.Alternate Facility(or Generator) U.S.EPA I Number J U Facility's Phone: Lu 18c.Signature of Alfamale Facility(or Generator) Month Day Year z rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. z. 3. Notice: State of California requires generator to photocopy and mail to 20.Designated Faciiity Owner or Operator:Cerfification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 days: Printed/Typed Name Signature P.O Bax 400 Sacramento,CA 95812-0400 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY