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Please print or type. Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone A.Modest c ' u em p WASTE MANIFEST CAi �tlf]<4:3ffi? r`R.`.a t.�.. ut,a) Ir 94 GBF 5.Generators Name and Mailing Address Generator s Site Address{!f different than mailing address) r',;i::t)CiAFL.0 i-RA TOR Vf_t+#WRA 34 14 WN 11)RA RE) WOCKT4:1K GA 952LWj Generator's Phone��.t��)-4 �3CD3[1 6.Transporter 1 Company Name U.S.EPA ID Number E'RICAN VALLA}!YVA:S'I f- OIL, JW, df�ti#l1CtrJ272�)2 7.Transporter 2 Company Name U.S.EPA ID Number SN11netAE:IY WASTE SOLL#"I# NS4 . llfk, NRdStk0011CP "4 8.Designated Facility Name and Site Address kAt gII-HA#+1f ,K)C(JItILxNA, i.LC. U.S.EPA ID Number I I '£i5 Vit-il-FE ROCK RD. CA09RDV;841Ki RA ICHO C.'CsRDOVA,CA 9ti742 Facility's Phoney t(:s y I i?lifft; ga. 96,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes No. Type Quantity wt./val.1' 140,NA 1983,r—TA J.''nat_P I,II'.kjm,m O.1 PC1111ir F IWO F":Nf- '=il Yc:trl-, ALIPHA1'1C'#-IVlafttlCARS4h1S w M 2. C7 3, 4. 14,Special Handling Instructions and Additional Information P'N OTALE# t64W1S-c)u AN I ICFREFZ.MIXFD VVI I"yf+NW,R FR (�t 1"dfS EMERGENCYGC1liIAf T CARLOS 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and l am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consont. I certify that the waste minimization statement identified in 40 CFR 26227(a)(if l am a large quantity generator or if I am a small quantity] { ){ q ty generator)is true. Generator's/Offerors PnniedfTyped Name Signature MOn#h, Day. Year, z Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature{for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pnnteofypgd Name � r Signature a Mo Year Z Transporter 2 Pnn edlryped ame Signature LK Doth Day Year F 18.Discrepancy 180,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection 1 Full Rejection 10b.Alternate Facility(or Generator) Manifest Reference Numher: U.S.EPA Ip Number U L Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Q Month Day Year z 19.Hazardous Waste Report Management Method Codes{i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. z. s. Notice: State of California requires generator to photocopy and mail to 20.Designated Facility Owner or Operator:CertlFcation of receipt of hazardous matanals covered by the manifest except as noted in Item 18a f Pnntedlryped Name QTSC with 30 days: Signature } P.O Box 400 J EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. Sacramento, CA 95812-0400 GENERATOR'S INITIAL COPY