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State of California—Environmental Protection Agency <br /> I <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form des(gned for use on elite()2 pitch)V sr Sacramento California <br /> I \--&ator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> Is UNIFORM HAZARDOUS ' 1 �~ is not required by Federal low <br /> WASTE MANIFEST of I <br />' 3 Generator s Name and Mailing Address 1_r � 't' ! j^��,.. [ A State Manifest Document Nvmber 23392'192 3 a 9 2'1 9 2 <br /> �� j R�4 0 B State Generator's ID "��j <br /> LO y; <br /> LO 4 Generators Phone ( 1 <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number I C State Transporter's ID[Reserved] <br /> LCID _ <br /> AMLRfGAN VALLEY WASYL OIL 1 L 1 1 1 1111, ( 81 d D Transporter':Phone <br /> O <br /> Co 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's 1D[Reserved] <br /> r�yti F Transporter's Phone <br /> Q m! rt,�•-�, ,s��yy <br /> V IhiMYi 7Y�c <br /> bite jnikpottq��K 10 US EPA ID Number G StatfaA,1y'LID0 0 0 1 9 0 8 1 b <br /> a 5,100 OLAW5 ROAD <br />�.r�3or I?IV'CfZL�ANKr CA 9,536-1C A ! 0 0 0 1 :v 0 8 1 6 H Facth 181tv'1 <br /> uL <br /> 12 S DOT Containers 13 Total 14 Unit <br /> Q 11 UDescription lmcldPShipping NHd Cld ID Nmber( <br /> uing roper ipping ame azarass anu <br /> O No Type Quantity Wt/Vol I Waste Number <br /> ? o NLN fICRA HAZARDOUS WASIF L.IQUID State <br /> 3 G f OILY WATER 1 00 1 T 3 i� (} tt?7 v ' � EPA/Other <br /> CN E b State <br /> N <br /> OD <br /> E EPA/Other <br /> R <br /> fV <br /> v A c state <br /> o T <br /> CD O EPA/Other <br /> R <br /> Wd q.-k. R <br /> H <br /> uZt EPA <br /> /Other <br /> V <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> OILY ANATER <br /> a_ <br /> w <br /> iU., <br /> c d <br />' a <br /> z 15 Special Handling Instructions and Additional Information <br /> a GLOVE"'? <br /> w EMi�f�0ENCY PHONE 209 607-8857 <br /> t- <br /> -1 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 /> < marked and labeled and are in all�especis in proper condition for transport 6y h ghway according to applicable international and national government regulations <br />' if I am a large quantity 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 /> practicable and tfiat i hove selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment OR, if I am a small quantity generator, I have made a good froth effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that 1 can afford <br />' O Panted/Typed Name f Signaty/e Month Day Year <br /> Lu T 17'Transporter 1 Acknowledgement of Receipt of Materials <br /> CZ— <br /> Oh Da Year <br /> �LLJ A Printed/T oer]Name Signature �� y <br /> LLJ "S <br /> 0 18 Trans orter 2 Acknowled imam of Race 1 of Materials r <br /> TPrinted/Typed Nome f Signature Month Day Year <br /> w E <br /> R <br /> Q <br /> [) 19 DiscrepancyIndication Space <br /> z F <br /> A <br /> C � <br /> 1 I <br /> C <br /> I 20 FauL Owner or Operator Certification of receipt of hazardous materials covered by this manifestezce t as noted in Item 19 <br /> YT Printed/Typed Name Signature Month Day Year <br /> Y <br />' DO NOT WRITE BELOW THIS LINE <br /> ' DT5C 8022A(1/991 Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />