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State of Calihmio—Emironmenld Prarection Agwry, <br /> Form Approved OMB No,20SO-0039(Expiia 9.30-991 See Instructions on back of�e b. Department of Toxic Subm <br /> snces Control <br /> Please print or type. Farm Msigned For use en dib(12-puw"-miler. Sacramento,California <br /> I. Generator's US EPA ID No. Monif.,t Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM`"iWARDOUS is not required 6y Federal law. <br /> s '� <br /> WASTE MANIFEST ,2 ) 4 , 1 5 [p of 1 <br /> 3. Generorors Nemo and Meiling Add., nGuI Waili A. S .Manifest Document Number 25162156 <br /> O &S4--R`)E s " 1 4 B. State Generator's ID <br /> e. Cmerro <br /> ar's Phone I (po7-9 i..M 1' / 1111111111111 <br /> N 5. Transporter 1 Company Nome 6. U$EPA D Number C. Slate Transporrols ID Nmoe d <br /> h <br /> w 6 T 6 D. Tronaponds Phan. 800-7324645 <br /> 8 AMERICAN VALLEY WASTE OIL <br /> 7. Transporter 2 Company Name R. US EPA ID Number E.Srou Trenspp-,,e,ID[R.ee .I <br /> F:. Tronsporter'i Phone <br /> Q <br /> Desi otd Faciliy�Name and Site Address 10. US EPA ID Number 'G. StaroFacili SID - <br /> CV< RIV�REIANK OIL TRANSFER <br /> CD 5300 CLAUS ROAD H. f.mltty's Phone <br /> '--10 RIVERBANK, CA 95367 1 9 8 116 <br /> 2088G3-8'181 <br /> Q Container, 13. Tocol Il, Unit <br /> 11. US DOT Description(including Proper Shipping Nam.,Hazard No Class,and ID Number) - - <br /> N V No. Type Quantity WI/Vol I. WasteNumber <br /> NON-RCRA HAZARDOUS WASTE LIQUID 5mN 221 <br /> 3 G ( OILY WATER ) T 00 G EPA/Other <br /> n E b. Some <br /> o N <br /> m E EPA/Other <br /> e R <br /> e A c. <br /> Sat. <br /> T <br /> 8 O EPA dher <br /> R <br /> ce <br /> w d. $tote <br /> Z <br /> W EPA/011ier <br /> V <br /> 'W <br /> J. Additional Description,for Materials Listed As. K. Handling Codes For Wastes Usted Abane <br /> Z <br /> O OILY WATER ° 01 e' <br /> psad <br /> d. <br /> Q <br /> 0 15. Special Handling Instructions and Addlilanol lnformabon <br /> i GLOVES <br /> = EMERGENCY PHONE 209.6674857 <br /> 16. GENERATOR'S CERTIFICATION: Ihereby declare that the contents of this consig mens are fully and occurate)y described aline by proper shipping nam.and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition M transport by highway according to applicable inromatianal and national govemmen,regulations. <br /> II I am a large quantity generator,I certify that I here a program in place ro reduce the volume and toxicity ol waste gomrabd w rno degree I here determined to be economically <br /> H procllaa6le and The,I hh elected the practicable method of hwnneM,storage,or disposal currently availa6la m.ms which minimi:.,the prunot and future threat to human hw116 <br /> and theenvironment;OR,if I am a small quantity generator,I have made a geed Faith effort es minimi..my wasro generation and select the best w.,te management method that if <br /> Omailable to me and 16at 1 can.;Ford. <br /> y Printed typed Name Signarer Month �SDay Ywr <br /> can Z t , S OG 10 4P <br /> W T 17. Transporter I A,kn.ldW..t at Receipt of M Ito ials <br /> jPrinld/Ty aero Signature Month Day Year <br /> W f O G Iola <br /> O0 IB. Trom nor2Acknowl emaN Rwd rd MaMials <br /> TPrimod/Typed Name sigm.wns Menth Day Year <br /> W E <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> 20, Facility Owner or O eroror Certification of rent t of hazardous materials cmerd 6,this m sr oncept as noted in Ilam 19, <br /> T PrinM1d/Typal NoDay <br /> . /�� �` ( /P SigwNn <br /> T �/F)N._ k�i O161716 <br /> DO NOT W ITE BELOW THIS LINE. <br /> White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC B022A(1/99) To: P.O. Box 3000.Sorsamwm,CA 95812 <br /> EPA woo-22_ <br /> 6174 . 0008 <br />