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Please print or type. (Form designed for use on elite (12 -pitch) typ6%0ler.) <br />DT S C- 00 , 0097 <br />Form ADoroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 5) Previous eMons are obsolete.:1`1 ' <br />f<. ' � DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10390.1130 <br />UNIFORM NA7ARDOUS 11-0DNu 2, Page t of 3. ErsrgencyRespoise Phone <br />WASTE MANIFEa9'LS-731001738243Ono <br />4. Manifest TraWng Number <br />FLE <br />5. Generators Name and M31'N AddressGenerators m9 address) <br />jnt('e - pO 0�0vCSV 5 <br />Generators Phone: ®C <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />AMERICAN VALLEY WASTE OIL <br />CAL000827878 <br />7. Transporter 2 Company Name <br />U.S. EPA 10 Number <br />8. Des`gna:ed ad'ity Name and Site Address <br />U.S. EPA 10 Mimter <br />RIVERBANK OIL TRANSFER <br />5300 CLAUS ROAD <br />CAL000190816 <br />RIVERBANK, CA 95367 209-863-8181 <br />Facilys Phone: <br />ga• <br />9b. U.S. DOTDesa(ption (erchn(fi!g Proper Skipping Name, Hazard Class, ID Number, <br />f0. Containers <br />1 t. Tonal <br />12. Unit <br />13. Praste Codes <br />No. <br />Type <br />Hfd <br />and Paddrg Group (d any)) <br />Quantity <br />Wtivol. <br />a <br />1. <br />NON-RCRA HAZARDOUS WASTE LIQUID <br />22 <br />�% <br />(USED OILY WATER) <br />00 1 <br />T T <br />G <br />Z <br />Z. <br />w <br />c� <br />3. <br />4. <br />14. Special HandGt:g Instructions and Additional tnformaton <br />�� <br />GLOVES' <br />`•' , <br />A <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the caiterts, Ws consignment are hilly and auxnalely dascnbed above by the proper sh'ppng name, and are classified, Packaged, <br />tional natiwal govemmenal regrdaWs. If export shipment and I <br />marked and labe'edrplacarded, and are In a8 respects in proper ccndit on for fthsp ccordag to apFYrab'e Inte�of <br />Exporter, I certify Ihal the contents of tNs consignment conform to the terms of the attached EPAAcknorM:edgmentConse, LI <br />am the Primary <br />I certiy that the waste mlr;mJuCon statement Ideriffed In 40 CFR 262.27(a) (d f am a large zruan[ty generator) or <br />neraton) Is true, <br />ernral s eros PAntediTyped Name e _ <br />y ea <br />'� <br />i— <br />16. Intemafional Sripments <br />❑ Import to U.S. ❑ Export from U.S. Port of entryreA: . <br />2 <br />Trans orters' nature for exports oro : Date leaving U.S.: <br />W <br />lu— <br />17. Transporteikkraa'edgm cf Race'pt of Materials <br />Transporter I Prnted7Type Name gnature <br />ay7 ea <br />O <br />d <br />(/ <br />Trans' erzPr�tedffy*Name Sgr+zture <br />" Day Year <br />18, Discrepancy <br />18a. Discrepancy Indication Space ❑ Qaantity ❑ Type ❑ Resldue <br />❑ Partial Resection <br />❑ Ful ReJetat <br />Manifest Reference Number: <br />18b. Attemale Faclry (of Generator) <br />U.S. EPA ID Number <br />V <br />Fact s Phone: <br />B <br />18x. S gnature of A!temate Faa'Sty (or Generator) <br />Month Day Year <br />19. Hazatdous Waste Report Management f.!e8wd Codes (.o., codes for hazardws v,aslebeabrent, dismal, and recycling systems) <br />r <br />20. Designated FaDQy Oxrer or OperaAr. Cerfficaton of r �I of haza1rd%rs,materia's oorered by the manifest except as , Item 18a <br />PrinteaTyped Name t Signature ' <br />Month Day Year <br />EPA Form 8700-22 (Rev. 5) Previous eMons are obsolete.:1`1 ' <br />f<. ' � DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10390.1130 <br />