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Stare of California—Ernironmental Protection Agency ——T_._-_ T — - - <br /> - - <br />' Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back of page 6. Department of Toxic Substances Control <br /> Please print or type Form designed for use on eht@ 112 pitch)lyr Yr Sacramento,California <br /> F3Generotor's <br /> M HAZARDOUS 1 �Jrator's US EPA ID No Manifest Document No `� 2 Page 1 Information in the shaded areas <br /> TE MANIFEST / /r, is not required by Federal law <br /> / < 1 ' tJ t ] of # <br /> ama and Mailing AddressI r 1 �. Ay Stole Manifest Dacdment Number <br /> 16 5 9,0 9 r <br /> h " v 7 a{: ta " 7 ' _ f r� f � � 3 State Generator's,ID,, r <br />' Generator <br /> a - ,U") 4 Generators Phone <br /> ` <br /> Ohl 5 Transporter 1 Company Name 6 US EPA ID Number C 'Stora Transporters 1D IRejerved f <br /> co <br /> 0o AME"IGAN VALLEY WASTE OIl. A I. 1110 0 a`I! T f3 7 a P� TtaAns¢or#ersPfraite <br /> aD 7 Transporter 2 Compan Name <br /> �- Y 8 U5 EPA ID Number Jw Slate Transporters ID Reserve 3 i _ <br /> F Trans_parygr"s Phone <br /> TLSO �L1RM 10 US EPA ID Number G Sw F li)yI3. <br /> Z 6300 CLAUS ROAD <br /> to f+IIVERSAK, CA 95W7 © 0 D 9 Q I� � � F[ �acillty'sPhone <br /> V11 US DOT Description(including Proper Shipping Name,Hazard Class and ID Number) 12 Containers 13 Total 14 Unit <br /> No T Quantity W!/Val f Waste Number <br /> 1. <br /> $tate., <br /> F a NOI�1"R+(`iFtA f'Io°1LAFt[90U9 WASTE L,.I01it4'1 <br /> ' 3 G ( OILY WATER) © 0 1 T 1 T O EPA/other E b 0 <br /> N <br /> aCo <br /> o E state <br /> N R EPA/~ <br /> Other <br /> 1VA r <br /> o T State <br /> OD O <br /> R EPA/Other <br /> 1 � d <br /> w Stats <br /> z <br /> LU <br /> V <br /> EPA/Other <br /> o <br /> J Descnplians for Materials listed Above IS Haricilirig Codes fai Wo$Ies Listed Above r <br /> OILY WATER <br /> LU <br /> a <br /> 0 15 Special Handling instructions and Additional Information <br /> H <br /> a GLOVES <br /> Uj EMER9ENCY PHONE 209-6i87-88b7 <br /> 1� <br /> 16 GENERATOR'S CERTIF"TION I hereby declare that the contents of this consignment are fully and accvraMiy described above by proper shipping name and are classified packed <br /> Q marked and labeled,and are in o11 respects in proper condition for transport by highway according to applicable international and national government regulations <br /> V <br /> IF I am a large quantity generator,I certify that I have a program in plate to reduce'the volume and toxicity of waste generated to the degree'I have determined to be economicallyy <br /> practicable and that I <br /> IV) hhova selected the practicable method o treatment,storage,or disposal currently available to me which minimizes The present and Future threat to human heolz <br /> ad 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 /> 0 available to me and that I can afford <br /> >- Printed/T ped Name ! 5i nater* <br /> V 1 g Month Day Year <br /> (? R 17 Transporter I Acknowledgement of Receipt of Materials <br /> w R Print /Typed Name <br /> Signature <br /> X r g Month Day Year <br /> sits 8 7 " I j r r f and <br /> P <br /> O R '18 Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name SignatureLu Month Day Year <br /> u' E <br /> R <br /> rZ F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by 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 11/991 <br /> EPA 8700-22 Yellow GENERATOR RETAINS <br />