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State of California—Environmental Protection Agency <br /> Form Approved o"°.�-ev2^:`•0-0039(Expires 9.30.99) See Instructions On hack Ol age 6. D spartment of Toxic Substances Con <br /> Please print or type. Form designed for use on elite(12-pitc, vriter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Inf rmotion in the shaded areas <br /> 'UNIFORM HAZARDOUSC- 1: -- s of required by Federal la- <br /> C,MANIFEST t, A L 0 G U 8 ) � � t% . 1 of <br /> 3. A. State Manifest Document Num er 1'� <br /> Generator's Name and Mailing Address � <br /> AMERICAN VALLEYi�VAST'E 011. inti:. � 16 tui f <br /> P.0 L'-1UK 34%) <br /> 4 ,,4•-s 1:3 t.01;t GL�:4i�F"f si B. State Generator's ID <br /> h <br /> h 4. Generator's Phone( ) <br /> f\ <br /> Transporter's ID[Resery <br /> CV 5. Transporter I Company Nome 6. US EPA ID Number C. State .] <br /> a�D r, <br /> F:tWi tip, At.t Beni s Cv s`!i}::s:'f f11. <br /> .. _ .... .• :.:_..._ .•r .. r..., t. ., �' D. Transporter's Phone - <br /> O <br /> ao 7. Transporter 2 Company Name S. US EPA ID Number E. State Transporter's ID[Reserve fF <br /> 1 F. Transporter's Phone <br /> J <br /> »J V <br /> t t i t e a i d s' 10. US EPA ID Number G. Stale joci jV's€ID �! � 1} .1 [7 C! Y3 <br /> Z <br /> � w - H. Facility'sP o <br /> Cr 7: <br /> F6 jy7v <br /> I <br /> O A CA J6' U9 <br /> "ti V 12. Containers 13. Total 14. Unit <br /> 11. US'DOT Description <br /> 1(inci <br /> cuding <br /> tPropetr Shipping Name,Hazard C1 ss,andIDNumber) r No. Type Quantity VI/Vol 1. Waste Number <br /> Z a. K101e �':L�RA FIt�. ARC)OUS WASTE L.:{,1t.Jii�l Slate <br /> `} F' EPA/Other <br /> 3 G IG <br /> E <br /> State <br /> o N b. <br /> co E EPA/Other <br /> v R <br /> v A c State <br /> C5 T <br /> 0 Q EPA/Other <br /> R <br /> Of state <br /> Uj d. <br /> w EPA/Other <br /> V <br /> LU K. Haling Codes for Wastes I sled Above <br /> Us J. Additional Descriptions for Materials Listed Above <br /> Z USED OIL & WATER Ot <br /> V) / <br /> rn <br /> LU <br /> Ce C. <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> Z EMERGENCY P�iONE MJ-667-8857Q <br /> w <br /> H <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the conte is of this consignment are fully and accurately described above by proper shipping no a and ore classified,pocked, <br /> Q marked,and labeled,and ore in all respects in proper conditior for transport by highway according to applicable international and national govern ent regulations <br /> V <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I h e determined to be economically <br /> a practicable and that 1{save selected the practicable method oft eatmeni,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> sn <br /> and the environment;OR,if I am a small quantity generator,I ave made o good Faith effort to minimize my waste generation and select the best asle management meth that is <br /> available to me and that I can afford. <br /> 0 + <br /> } Print /Typed Name Signage Month Day Ye. <br /> I <br /> Z <br /> w 1 17. Transporter 1 Acknowled emenYof Receipt of Materials <br /> l7 R Month Day. Yep <br /> p Printed/Typed Name Signature _ : <br /> P f. ..LU <br /> . <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month <br /> Day Ye <br /> 0 <br /> I <br /> w E <br /> rn N <br /> la.J 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20. Focili -Owner or Operator Certification of recei t of hazardou materials covered b this mtinifest exce t as no)ed in Item L9.'' <br /> T Printed/T.yped Name <br /> Y Signature l' j Mont} Day Ye <br /> xl �� r / G• / !, <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> can a7nn-11 <br />