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State of Cal forma—Environmentol Protection Agency:9 <br />'Form Approved(;;MB 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 designedfor use on afire 112 pitch)h----Y der E i Sacramento California <br /> ,UNIFORM HAZARDOUS jt aerator s US EPA ID No Manifest Document t 14 2 Page 1 Information in the shaded areas <br /> t ��%! is not required b Federal law <br /> WASTE MANIFEST � � � i,. (�,� � � � 1 � � � ! �" of � q y <br />' 3 Generator's Name and Mailing Address C1 A State Manifest Document Number 21653094 <br /> y ry ,p <br /> _ - i re <br /> B Stela Generator s ID <br /> J � <br /> 11 4 Generator s Phone <br />'�4 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved <br /> f <br /> o 4SMERIICAN 'VALLEY ,AS � 01! +� � x �� to � ,} ► tt � F3 D Transporter s Phone F3(0) x`312,4646 <br /> O <br /> F 7 Transporter 2 Company Name B US EPA ID Number E State Transporter s ID[Reserved <br /> QF Transporter s Phone <br /> 10 US EPA ID Number G Stata,Fa bly�s 1% j) 1U I <br /> #jnF+ tPL4.t ROADA s+ <br /> H Facsltt�s Pbone <br />) O RIV FMANK, CA 95367 f>< ' # ft O k3 I I <br /> e 12 Containers13 Total 14 Umt <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> = a NON-ItCRA �JAZAIZDOUS WA143I- LIQkJ10 State <br /> ~ ( 01L Y WAYER ) 0 0 Q 3 T1 /y 1+ EPA/Other <br /> b <br /> E Stale <br /> N <br /> ao E <br /> R EPA/Other <br /> A c State <br /> T <br /> 0o O <br /> w R EPA/Other <br />�u d State <br /> V EPA/Other <br /> LU, <br /> J Addi}ional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> OILY WATER 01 6 <br /> .n <br /> LU <br /> c d <br /> 15 Special Handling Instructions and Additional Information <br /> a �.sd.OVES <br /> 7 f'-mv,14004cy PHONE 209-43$474485t <br /> 1J <br /> Q16 GENERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed <br /> U ' rr`arked and labeled and are in all respects in proper condition for transport by highway according to applicable International and national government regulations <br /> a If I arr)o large quantity generator I ceftiFy that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and chat 1 have selected W6 practicable method of treatment storage or disposal currently ovoJable to me which minimizes the present and future threat to human heat3dlth <br /> and the environment OR if I am a sma11 quantity generator,1 have madeia good faith effort to minimize my<wpsta gelseration and select the best waste management method that Is - <br /> 0 - available to me and that I can afford <br /> Pn red/ yped N e Signet e y antpDa Ye <br /> ., . It e ft6k ome"I b�, �� hu L . , / ., _f. <br /> Vr T 17 Trans orter 1 Ack owled emen of Rec'ei t of Materials [ <br /> t1i <br /> 5n e r/jyp�d <br /> No Si re -FcnF}i 1dashYt " a <br /> x !Yj (�l. �,(f/Com/ (1 1� L <br /> B 1$ Tr'bns otter 2 Acknowlecillement of Receipt of Materials <br /> Printed/Typed Name Signature Month Day Year <br /> LU t <br /> Q R <br /> F F screpancy Indication Space <br /> A <br /> C <br /> f <br /> 1 L <br /> I 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed NameSignature Month Day Year <br />' DO NOT WRITE BELOW THIS LINE <br />'DTIC 11022A 11/991 <br /> EPA 8700-22 Yellow GENERATOR RETAINS <br /> ` <br />