Laserfiche WebLink
State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back Of "^e 6. <br /> Please print or type. Form designed for use on elite(12-pitch)ty er. P Department of Toxic Substances Control <br /> Sacramento,California <br /> 1. �—erator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS '� �., 1 is not required by Federal law. <br /> WASTE MANIFEST - '� "} r' G' ) i ('• `� of <br /> 3. Generator's Name and Mailing Address � I A. State Manifest Document Number Y <br /> r j �% 1yr r y��, t�' B. State Generator's ID <br /> LO A. Generator's Phone <br /> n <br /> (V 5. Transporter Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.[ <br /> LO <br /> ao <br /> g AMERICAN VALLEY WASTE OIL IA L. J s" 8 2 '71 / 8 D. Transporters Phone 80&,732,-4645 <br /> of 7. Transporter 2 Company Name 8. US EPA ID Number <br /> P P Y E. State Transporter's ID[Reserved.] <br /> ' J <br /> QF. Transporter's Phone <br /> U 9. Desi noted F cility Name f Site Addp� 10. US EPA ID Number G. Stat Facility' ID <br /> a 0 1 <br /> Q RIVEftwA�flK OIL.TtA2t 31-:�R <br /> W 53W CLAUS ROAD H. Facility's Phone <br /> ' RI'JcTR B ANIS. C;A 953:17 IC JA I L 10 10 10 Il 19 10111 <br /> 109-863-8181 <br /> `9 Q . <br /> U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13Total 14. Unit <br /> No. Type Quantity Wt/Vol I. Waste Number <br /> = a NON-RC RA HAZARDOUS US WASTE LIQUID stare 221 <br /> Ca (OILY WATER) n G 'i T 4./ 1 3 EPA/Other <br /> cv E <br /> O N b. State <br /> 0000 E <br /> -4 R EPA/Other <br /> C14 A <br /> o T c State <br /> co O <br /> R EPA/Other <br /> Lu d. State <br /> Z <br /> Lu <br /> U EPA/Other <br /> Lu <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 0 OILT WratT�Fi a. 01 b. <br /> N <br /> W <br /> CC <br /> J c. d. <br /> Q <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> a <br /> GLOVES <br /> W I tfdrL=RG NC Y PHONAE 209-667-66157 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If 1 am a large quantity generator,I certify that I have a progrom in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> cn practicable and that I have selected the practicable method aF treatment,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 small quantity generator,I have made a good faith effort 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 /> } Printed/Typedrtlame Signature 1 Month Day Year <br /> ZIt iC'; �Cr— moi,•. .�/, ) L.�, f tea" ;'� ! % �,� <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> U` R tt it t <br /> w p Printed/Typed Nam' Signature .f, ,:�r" Month (1a Year <br /> "s �CV� rrt fit F� y/ <br /> J0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> w E <br /> . -T <br /> Q <br /> R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I 20, Facility Owner or Operator Certification of receipt of hazardous materials covered by this m ifest exce t as noted in Item 19. <br /> T Printed/Typed No �/ f Signature rri, Month Day Year <br /> Y /r' r <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />