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tate of California—Environmental Protection Agency !yF <br /> arm Approved OMB t(o.205070039(Expires 9.30.99) See Instructions on back of pc Deporti ieni of Toxic Substances Control <br /> lease print or ;;pe. Form designed for use on elite(12-pitch)typewriter. Sacramento,California <br /> 1. Generator's US EPA I No. Manifest Document No. 2. Page I Informati n in the shaded area <br /> NIFORM HAZARDOUS <br /> WASTE MANIFEST �' f i t� t s ^� Ir of ? snot re aired by Federal law. <br /> 3. Generator's Name and MoilingAddA. Slate Manifest Document Number <br /> Address A1AEt ;f C::AN VALLEY W S'VE. Ott- !NC �' �' � ��1 �' U <br /> P.0 !iOX 340 <br /> s B. State Generator's ID <br /> t `Wl 73'2_484 D".LHI, CA 95316 <br /> 4. Generator's Phone 1 ) <br /> l 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID[Reserved.] <br /> 1 <br /> s AME.HKDAN VAL.I.G.Y WA1-:tL: 011.. (` L ( f` F.. r D. Transporter's Phone <br /> 800.73' 4646 <br /> 7. Transporter 2 Company Nome 8. US EPA ID Number E. Stole Transporter's ID(Reserved.) <br /> F. Transporter's Phone <br /> 9, pes' noted F c'li ame a d.Si a re S 10. U EPA ID Number G. State Facility's ID <br /> !; n4yy.lf:. � 1 .:f-t �, r. _ " <br /> i'.IJU 1:L.7cllJ j{rJ/a�3 H. Facility's Phone <br /> > HiVr:I-4611--1K CA 958i -1 f q19 (1 0 116 ' <br /> zos-663: 1 81 <br /> 11. US DOT Description(including Proper Shipping Nome,Hazard Closs,a No <br /> d ID Number) Containers 13. Total 14. Un t <br /> J No. Type Quantity Wt/Vo I. Waste Number <br /> 0. IitJ!'s-h{i:; i11 HAZARDOUSbWA\S'; i. !.iC?l iL store c <br /> I,) C.)I(_ t 1 t l 'I ; I 1 '�, / C EPA/Other <br /> G <br /> E b <br /> N slate <br /> i E <br /> r R EPA/Other <br /> i A <br /> c Slate <br /> T <br /> i O <br /> • R EPA/Other <br /> J d, State <br /> � EPA/Other <br /> J <br /> J. Additional Descriptions for Materials listed Above K. Handling Codes for Wastes Listed A iove <br /> USED OIL. &WATER. 01 b. <br /> i <br /> J <br /> - C. d. <br /> C <br /> 15. Special Handling Instructions and Additional Information <br /> i..i.sCP—LNC'( PHONE 2fi'J-667-857 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of thi i consignment are fully and accurately described above by proper shipping name and re classified,packed, <br /> f marked,and labeled,and ore in all respects in proper condition for tra sport by highway according to applicable international and national government re ulations. <br /> 1 <br /> If I am a large quantity generator,I certify that I have a program in pace to reduce the volume and toxicity of waste generated to the degree I have dere mined to be economically <br /> practicable and that I have selected the practicable method of Irealmen,storage,or disposal currently available to me which minimizes the present and fur re threat to human health <br /> and the environment:OR,if I am a small quantity generator,I have mode a good faith effort to minimize my waste generation and select the best waste rr anogement method that is <br /> avoilable to me and that 1 can afford. <br /> Printed/Typed Name Signafur / ly nth Day Year <br /> J 9 17. Transporter I Acknowledgement of Receipt of Materials <br /> A Printed Typed Name Signa(are nth Day - Year_ <br /> R 18. Transporter 2 Acknowledgement of Receipt of Materiols <br /> R Printed/Typed Name Signature /` nth Day Year <br /> J E s <br /> R <br /> j19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. F cility Owner or O erotoc.Certification of receipt of hazardous materic Is covered by this manifest except afnoted in Item 19. <br /> T Printed p_gd 4cmi Signature A` / onth Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> I)TSC ao99A I1/991 <br />