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Form Approved OMB No.2050-0039(Expires9-30-991 $6E instructions On bOCK Of 1109@ O. Department of Toxic$ubstdnces Control <br /> Please prinf or typsi. Form designed for use on elite 112-pitch)typewriter. _ Sacram mm,California <br /> [I F3. r�n.n, <br /> NIFOt <br /> HAZARDOUS nerator's US EPA ID No. Manifest Document 2. age 1 Information in the shaded areas <br /> -*D <br /> n is not required by Federal law. <br /> 1 WAMANIFEST 7 3 al „� <br /> ror'sand Mailing Address (� Q r ' J A. State Manifest Document Number 22968468 2 9 6 8 4 6 8 <br /> �` ��,.F1 `�/�TsPAM LO B. State Generate),ID <br /> LL . <br /> nA.Gemnaror's Phone 4 L(-1.T (- R1' <br /> N 5. Transporter I Company Nome 6. US EPA ID Number C. State Transporter's ID(Reserved.( <br /> WN <br /> C? D.Transporter's Phon <br /> o AMERICAN VALLEY WASTE OIL $ 2 8 718 X5047324645 <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State [Reserved] <br /> I <br /> Transporter's ID . <br /> ,,A0 P _ <br /> W F. Transporter,Phone <br /> V J t d 10. US EPA ID Number - G. Stat Fa ly ID <br /> OD ¢ diVER11*k .i pm°I ��i� �'�1 L 1010101 1 9 0 8 1 8 <br /> CD z 5300 CL4US ROAD H. Facies,Phone <br /> o R IVERUAN K,CA 95367 P IA L. 0 111 P 111111 0 $ II a 20%4363-Ri$1 t :. <br /> N Q 11. US DOT Description(including Proper Shipping Name,Hazard.Clo6,and ID Number) 12. Containers 13. Total IA. Unit <br /> V No. T .Quantity Wt/Vol I. Wast,,Number <br /> NON-RCRA HAZARDOUS WASTE LIQUIDstate 221 t { <br /> G (OILY WATER) 9011 T T EPA/Other <br /> G < <br /> i / r <br /> o N b. _ State <br /> co E EPA/Other <br /> v R <br /> A c. state <br /> o T <br /> 0�0 O <br /> R EPA/Other <br /> w d. State <br /> Z <br /> ts.t EPA/Other <br /> V <br /> w <br /> to <br /> J. Additional Descriptions kr Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z OILYWATER R 01 b. <br /> 0 <br /> N <br /> W <br /> m a d. <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> a CLOVES <br /> Z <br /> = EMERGENCY P1 ION 209 067--8857 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper ship ing name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to app licable international and nationaPgovernment regulations. <br /> J <br /> If I am a large quantity generator,I certify that have a program in place treduce the volume and toxicity to <br /> of womb generated to the degrdegreehave determined to be economically <br /> i practicable and that 1'rselected the practicable method o treatment,storage,or disposal currently available ma which minimizes the present and future dtoose! human health <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O <br /> Printed/Typed Name Signature Month Day Year / <br /> Z r /1 t � f <br /> T 17. Trans rier 1 Acknowledgement of Recei t of Matenals `"-- <br /> W q'NI Printed/Typ�ame Signature r Monlli /Day Year <br /> LL 0 18. Trans iter 2 Acknowled errant of Receipt of Materials <br /> O i Printed/Typed Name Signature Monde Day .Year <br /> w [ <br /> R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I 20. Facili Owner or Operator Certification of recei t of hazardous materials cowrod b this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8021A 11/991 Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />