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Slate of California—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page b Department of Toxic Substances Control <br /> Please pint or type, Form designed For use on elite 112 pitch)typewriter Sacramento California <br /> LNIFORM HAZARDOUS �1 Generator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST {` L/ � S 9j . � 9 60 of isnot required by Federal law <br /> l <br /> 3 Generator s Noma and Mailing Address (�_ bba pcL A State Manifest Document Number 21806896 1806896 <br /> � �•J B Stela Generator s ID <br /> 4 Generator s Phone <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved I ; <br /> �1 <br /> m <br /> D Transporter s Phone <br /> o AMERICAN VALLEY WASTE OIL A I�L fl U 0 9 2 7 7 8 BM-792-4"5 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved I <br /> y Q F Transporter's Phone <br /> U 9 Designated Facility Name and Site Address 10 US EPA ID Number G State FaciliVs ID <br /> I g AMiERIC:LEAN INC jN]_Vj 4 91812131518141 q 3 <br /> 1W 430 ALMOND ON HFacility s Phone <br /> 10 T <br /> 311 VERSPRINGS. NY 89429 <br /> 114—C 12 Containers 13 Total 14 Unit <br /> V 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type Quantity WI/Vol I Waste Number <br /> z a State <br /> NON-RCRA HAZARDOUS WASTE LIQUID 221 <br /> 3 G ( OILY WATER D Q 1 i ti ^ t G EPA/Other <br /> E b State _ <br /> N <br /> 00 <br /> co E <br /> NR EPA/Other <br /> v A c State <br /> o <br /> T <br /> co O <br /> .' R EPA/Other <br /> s1u d State <br /> Z 1 <br /> LLi ^ <br /> V EPA/Other ;r-; _ <br /> w € r^ <br /> J Additional Descriptions for Materials listed Above w K Handling Codes for Wastes Listed Above <br /> T ,I t <br /> OILY WATER a` !r 01 b <br /> W <br /> .S <br /> � r c <br /> Q � F <br /> Z, <br /> O 15 Special Handling Instructions and Additional Information <br /> a GLOVES <br /> z <br /> W EMERGENCY PHONE 20$-667-US7 <br /> x <br /> a 16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately 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 /> J IF I am a large quanta generator I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicall <br /> � g yy <br /> a practicable and that I ave selected the practicable method Treatment, storage or disposal currently available to me which minimizes the present and future threat to human healih <br /> and the environment OR if I om a small quantity generator I have made a good faith effort to ze my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br /> O <br /> } PSP t/e`d/Typed e t (tel+107 id '` Signature {Month Days Year <br /> z "�+f I,) <br /> l I <br /> Z5 T <br /> R 17 Trans orter 1 Acknowledgement of Receipt of Materials <br /> W 8 Primed/T/yped Name Signature Month Day Year 1 <br /> tv <br /> 11j s <br /> P <br /> w 0 18 Transporter 2 Acknowled ement of ftecei t of Materials <br /> O i Printed/Typed Name Signature Month Day Year <br /> w E <br /> rn R <br /> V19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20 Faci i Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A (1/99) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />