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• <br />., rc.....,d—b.nad en..me nn elite 119_nirchl hmewriterl <br />• OTSC- 01551.2254 <br />Form Approved. OMB No. 2050-0039 <br />rmc <br />ac"nn,._ r.._.., .,r_....._.., <br />1. Generator 10 Number <br />2. Page tof <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />UNIFORM HAZARDOUS 1 <br />003920173 F LE <br />WASTE MANIFEST C A L 0 0 0 8 2 7 8 7 8 <br />, <br />5. Dimensions Name and Mailing Address Generators Site Address (it different than mailing address) <br />AMERICAN VALLEY WASTE OIL INC <br />P.O BOX 340 <br />Generators Phone:DELHI, CA 95315 209-667-8857 <br />6. ransposter t Company ame U.S. EPA ID Number <br />AMERICAN VALLEY WASTE OIL i'Al 1111111110,89711171% <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA 10 Number <br />DK-DIXON <br />7300 CHEVRON WAY CATOBOO12602 <br />RI�I CA N 95620 707-693.6008 <br />Fapr s <br />go. <br />gb.U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Carl nersQu <br />Total <br />12.Unit <br />Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Padding Group (if any)) <br />amBty <br />Wt. <br />NON-RCRA HAZARDOUS WASTE LIQUID <br />o <br />(USED OILY WATER) <br />0 0 1 <br />T T <br />ZS' <br />G <br />z <br />z. <br />w <br />3 ) <br />4. <br />14. Special Handling Instructions and Additional Information <br />Profile 9 DK100082 <br />TRUCK#'7 <br />15. GENERATOR-S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ate fully and accurately described above by the proper shipping name, and are <br />assified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport awarding to applicable international and national govemmental regulations. If export shipment a <br />I am the Primary <br />Exporter, I cerlity that the contents of this consignment conform to the terms of the attached EPAAckrowledgment of Consent. <br />I certify that the waste minimization statement identified M 40 CFR 262.27(a) (I I am a large quantity generator) or (b) (if I am a small quantity generator) is We. <br />eneratoesr0 emus not ype ame Moth Day 75ar <br />—a <br />F <br />16. IntemaGanal Shipments <br />❑ Import to U.S. ❑ Export from U.S. Portof entrylexit: <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. TranspaterAcknowfedgment of Receipt of Materials <br />Transporter 1 Print ype Name ignalure / <br />n ay ear <br />a <br />Z 6 <br />QTransporter <br />2 Printedflyped Name ignaluTe re <br />on ay Year <br />K <br />Discrepancy, ' <br />i18. <br />18a. DiscrepancyIndication Space ❑ Quantity ElType ❑ Residue ❑ Partial Rejection ❑ Fu0 Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) 0.S, EPA ID Number <br />V <br />LL <br />F82 5 Phone: <br />W <br />18c. SignaWre of Alternate Facility(or Generator) Month Day Year <br />Q <br />CD <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />i. <br />2. 7. <br />4, <br />20. Designated Facility Owner or Operator: Cefcation of receipt of hazardous materials coverad by the manifest except as ni 18a <br />PrintedzTyped NameSignature <br />1Q-. <br />onM Day Year <br />e, r,11 <br />AL -se .i <br />34 110 <br />EPA Form 8705722 (Rev. 3-05) PreviousLdilions are obsolete. L..AESfGNATO-PACILITY TO DESTINATION STATE (IF REQUIRED) <br />