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' State of Cahforma--Environmental Protection Agency <br /> Form Approved OMR No 2050-0039(Expires 9 30 991 See Instructions an back of page $ Department of Toxic Substances Control <br /> Please print or type Form designed for use on ehle(I2 pitch)typewriter Sacramento California <br /> 1 Generator s US EPA ID No Manifest Document No 2 Page T information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal low <br /> WASTE MANIFEST A 4 7 j� a <br />' 3 Generate/,Na and Main Ad res A Slate Manifest Document Number <br /> + ��a r ��� >r VA � �' �� 2095$452 <br /> 0 t1 �� �t iyD <br /> LO 451 8 State Generator's 1D <br /> ,5 T) r 75C C L <br /> LO <br /> 4 Generator's Phoma <br /> � 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved) <br /> o EAIOAN VALLEY WASTE OIL T' 81718 o Transporter's PhonP8EM-7=-4*45 <br /> L0 <br /> C? 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID Reserved I <br /> J� F Tronspartels Phone <br /> a ----------------- <br /> V 1 b&,?ftAr'kftrdtt Vo,INC 10 US EPA ID Number G 510111LIFOC1111Y6100 9 <br /> a 700 S SOTO ST H Facility's Phone <br /> M 0 1 A, CA 90023it 2 71 018 532-5D8.8S77 <br /> 12 Containers 13 Total 14 Unit <br /> U 11 US DOT Description(including Proper Shipping Name,Hazard Class and ID Numbed No Type Quantity WfIYo1 F Waste Number <br /> z NON-RCRA HAZARDOUS WASTE LIQUID Sro>e <br /> x 221 <br />' 3 G (OILY WATER) 0 0 1 T T 0 O EPA/Othcr <br /> o N b i state <br /> � # <br /> co E )�. EPAIOlher <br />' <r R <br /> C14 A State <br /> o T <br /> m O EPA/Other <br /> R t <br /> d State <br /> sur l' <br /> w EPA/Other <br /> t:> ` <br /> Addrhonal Desmptions for Materials Listed Above K Handling Codes For Wastes Listed#tbove <br /> a OILY WATER ° 0f b <br /> � r rX <br /> d <br /> J <br /> a <br /> Z 15 Special Handlinginstructions and Additional Information <br /> Tr D / r i/ � ( eIV <br /> a <br /> 2 GLOMES <br /> EMEROENGY PHONE 209-66743857 !� <br /> T6 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are clossdred pocked <br /> Vmarked ano labeled and are in all respects+n proper condition for transport y highway according to applicable international and national government regulations <br /> J <br /> - If I am a large quantity generator,t certify t <br /> iFy that 16ava a program in place to reduce the volume and toxicity of waste generatedo the degree 1 have determined to he economically <br /> Z practicable and that 1 haye selected the rachcable method aF treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> in <br /> and the environment,OR,if I cu a s ;quantity generator I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I cpm o0ord - a <br /> U Fjjz��6�L <br /> /Typed i�1gn re ! f Month Pay year <br /> C? <br /> 1`7 er f Acknowfed ement of Receipt of Materials <br /> wy <br /> Printed/Typed Name Signature r� th Year <br /> A © r J1'} 0 1611 <br /> s <br /> U- 0 18 Trans rte,2 AclsnowI d ement of Receipt of Materials <br /> 0 T Panted/Typed Name Signature <br /> Day Year <br /> � E <br /> R - J <br /> V19 Discrepancy Indication Sp=., <br /> F <br /> A <br /> C <br />' 1 <br /> i <br /> I 20 Fac+h Owner or Operator Carhfeeatian of receipt of hazardous motenala covered 6y this manfasf exrppt as Dred in Ir m 19 <br /> T Printed/Typed Name =131Ur ` , � 5Month Doy Year <br /> 41 ._ ._ <br /> Yule / <br /> VA 'SiA <br /> DO NOT WRITE BELOW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> 22A it/99} (Generators who submit hazardaus waste for transport out of-state, <br /> DTSC 80 <br />' EPA 07022A 1 produce completed copy of this copy and send to DTSC within 30 days[ <br />