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State of California—Environmanlal Prosection AgencySee Instructions on bac <br /> i <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) k of pR•^e 6� ntrol <br /> Please print or hype. Form designed For use on elite(12-pitch) or. <br /> ornio <br /> 1. Generator's US EPA ID No. Manifest Dowment No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS } is not required by Federal low. <br /> WASTE MANIFEST fi of <br /> 3. Generator's Nome and Mailing Address ' U j R/L k-4.xN( A. Stale Manifest Document Number /1 3793391 <br /> 4A N,5I �RadO (_ <br /> O '1 B. State Generator's ID <br /> vii 4. Generaror's Phan. � ) 1 --TOD CU f ( <br /> n <br /> C. State Transporter's <br /> N S. Transporter 1 Company Name 6. US EPA ID Transporter's ID[Reserved.[ <br /> n <br /> o AMERICAN VALLEY WASTE OIL C A L 0 0 C B 1 ' '1, D. Transporter's Phone �-7;y2-41145 <br /> 0 <br /> °D 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> Q .,I��ts, .4� <br /> C1�U q. r"Afldiw"Maris/RI PER 10. US EPA ID Number G. Stalefn<iLyLD/) Q 9 0 8 C. <br /> 1:10Z CLAUS ROAD H. Facility's Phone <br /> �o RIV[RFIANK, CA95387 C A L O C 0 1 9 C i3 116 2;Z8(-,3-81 8,1 <br /> tiQ 12. ners 13. Total 14. Unit <br /> }U 11. US DOT Description)including Proper Shipping Name,Hazard Class,and ID Number) Contai <br /> No. T e Quantity Wt/Val I. Wast.Number <br /> N= NON-RCRA HAZARDOUS WASTE LIQUID <br /> State <br /> OILY WAl ER ) 00 1 T T y G EPA/Other <br /> 3 G _, . . <br /> E b State <br /> o N <br /> as E EPA/Other <br /> v R <br /> A c- state <br /> o T <br /> 00 O EPA/Other <br /> R <br /> w d. Stale <br /> Z <br /> Z <br /> V EPA/011ier <br /> w <br /> 1 <br /> Z N J. Additional Descriptions for M°lerials Listed Above K. Noodling Codes for Wastes Listed Above <br /> { <br /> o D1Lv WATER b. <br /> W <br /> Mk- <br /> ad c. d. <br /> 0 Z <br /> 15. Special Handling Instructions and Addgionol Information L.-I l n t rl ! N r ( a 1 ud N 1a <br /> a GLOVES 'l R_ SP lY 'v n5�o5 <br /> Z EMERGENCY PHONE 209.667.885' rV Y <br /> J 16. GENERATOR'Sr CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipping name and are classified,packed,. <br /> Umdrked,and labeled,and are in all respects in proper condition for transport by highway according toapplicable international and national government regulations. <br /> I <br /> J IF I am a large quanliq generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> 't N practicable and that hove selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human Freak <br /> the environment;OR,if I am a small quantity generator,I have made a goad faith efiI 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 /> r Printed/ Name t - , Signature Month Day Year <br /> Z >( /i Il i G.- ;'1�.,r ' h -L.--�' '1. 1 -� <br /> W T 17. Trans orter 1 Acknowledgement of Recei t of Materials <br /> R <br /> w A Printed/Typed Name alure / Month Day Year <br /> P i0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O j Printed/Typed Name Signature Month Day Year <br /> W E <br /> R <br /> 1 V 19. Discrepancy Indication Space <br /> Z E <br /> _ p <br /> C <br /> 20. Facili Owner or Operator Certification of receipt of hazardous materials covered 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 /> I <br /> DTSC 8022A(1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br /> r <br />