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Please print or type.,(Form designed for use on elite(12-pitch)typewriter.) 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 lr t,o � �j 6 1 ��4�-�tB7$Ef�A7 O 17 3 8 r-7 FLS_: 5.Generator's Name and Mailing Addresstry �4J Generator's Site Address(if different than mailing address)C,l+ «wy 14wyIS Generator's Phone: 6.Transporter 1 om an ame U.S.EPA ID Number AMERaCI�N'VALLEY WASTE OIL CAL000827878 7.Transporter 2 Company Name U.S.EPA ID Number 8.D eRBA 74-M0 A ,}FET? U.S.EPA ID Number 57,00 CLAUS ROAD CAL000190016 `FVFPbANK.CA 95381 209--863-8151 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total, 12,Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtNol. 1. NON-HURA HAZANDOUS WASTE LIQUID 221 - ,. {USEn Cll!_lr 41V,'ATFR) 0, 0 1 T 1' J Z 2. .._ w s s 3. 4. 1 r I 14.Special HandlinifteWa3dAdditional Information 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations,If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. enerator's! eror's PrintedlTyped Name Signature on ay ear C7. �. 16.International Shipments' t- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: -- Z Transporter signature for exports onl : Dale leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials � Transporter 1 Printed/Typed Name Signature ont ay "ear O0. U) !y Signature r , ` Month Day sear za Transporter rintedlTyped Name r �'' t- 18.Discrepancy - 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U d r+- Facilil's Phone: Month Day Ye,r W 18c.Signature of Alternate Facility(or Generator) a I I i - Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) -_ 0 1 � 2. 3. 4. ;LI - 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a % Month Day Yea , Printed/Typed Name S nffi0{e % EPA Form 8700-22(Rev. 05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERA i)R