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Slate of California—Environmental Protection Agency <br /> Form Approved OMB No 2050-D039(Expires 9 30 99) See Instructions on back of page b Department of Toxic Substances Control <br /> Please pint or type, Form designed for use on elite 112 pitch)typewriter Sacramento California <br /> LNIFORM HAZARDOUS �1 Generator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST {` L/ � S 9j . � 9 60 of isnot required by Federal law <br /> l <br /> 3 Generator s Noma and Mailing Address (�_ bba pcL A State Manifest Document Number 21806896 1806896 <br /> B Stela Generator s ID <br /> 4 Generators Phone <br /> Cl 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved I ; <br /> as <br /> D Transporter s Phone <br /> a AMERICAN VALLEY WASTE OIL A L U 13 O S12171817 B � 13I11C1-732-4645 <br /> OD 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved I <br /> QF Tronsporter's Phone <br /> V 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility's ID <br /> 1 a AME=RIC:LEAN INC N]V1 4 91812131 -518141 q 3 <br /> y o 2430 ALMOND OR HFacility s phone <br /> I q1t V RSP <br /> J 12 Containers 13 Total 14 Unit <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) <br /> V No Type Quantity Wt/Vol I Waste Number <br /> z a State <br /> NON-RC RA HAZARDOUS WASTE LIQUID 221 <br /> 3 G { OILY WATCf4 ) 0 0 1 i T ti � 1 r � G EPA/Other <br /> 04 E b State <br /> o N <br /> 00 <br /> co E <br /> N R EPA/Other <br /> `3 A c State <br /> o T \ F <br /> cO <br /> o <br /> .0R EPA/Other <br /> s1u d State <br /> z 1 <br /> LLi ^ <br /> V EPA/Other ;r-; _ <br /> w € r^ <br /> J Additional Descriptions for Materials listed Above w K Handling Codes for Wastes Listed Above <br /> OILY WATER -�� r � a` !r Q� b <br /> � r c <br /> a F <br /> z <br /> O 15 Special Handling Instructions and Additional Information <br /> a GLOVES <br /> z <br /> W EMERGENCY PHONE 20$-667-US7 <br /> x <br /> a 16 GENERATOR S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed, <br /> Vmarked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> J If I am a large quanti generator I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicall <br /> � g yy <br /> a practicable and that I ova selected the practicable method Treatment, storage or disposal currently available to me which minimizes the present and future threat to human heahh <br /> and the environment OR if I om a small quantity generator I have made a good faith effort to 70—my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br /> O <br /> } P ted/Typed a - t ' Ft a+i l iJ i s Signaturp' Month Day Year <br /> WT 17 Transporter 1 Acknowled ement of Receipt of Materials <br /> acR LU <br /> ai Pnnied/Typed iJame Signature Month Day Year <br /> U- 018 Transporter 2 Acknowledgement of Races i of Materials <br /> 0 T Prtnted/Typed Name Signature Month Day Year <br /> w E <br /> � R <br /> a <br /> V 19 Discrepancy Indicption Space <br /> z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A (1/99) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />