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May 06 10 12:32p Julie Huber 209-668-3880 p.2 <br /> Phrase priit or type.IForm cesigned for use ottelit4(12-pitch)typewriter.) Form Approvec.CMB No.2.60-0039 <br /> �,:�Genaratori!DyNwrnbvi .Page 1 of 3.Emergenc Response Phorre 4,.1 nif st Tracking Number <br /> UNIFORM HAZARDOUS C A L O 0 0 8 2 $ 7 $ 1 2.�,8t.!_"a! 8F3)I� � � ��j�!�9 FL� <br /> WASTE MANIFEST +� <br /> 5.Gene-ator's Name nd A dr ss Generator's SitsAodress(if different than mailing address) <br /> ,�@;pi eRA VAtL.L.FY WA,13'f't- OW.INC <br /> P-0 aox UG <br /> nELHI,CA 89 15 2W-"j.FI 5;, <br /> Generaars PFwne: <br /> 6.Transporter I Compary Name U.S.=PA.ID N.nnber <br /> AMIFRI CAN VALLEY WA;i' E €SIL. CAL,00082 4i d <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 64 t FA AL SERVICES U.S EPA:DNumter <br /> 1515 sourhi RIVER ROAD i}3 k3 <br /> 1F/cc6t SACRAMENTO-CA 9%91 911115-371-5741 <br /> Facility's Phone: <br /> ga 91b.U.S.OCT Description(inctudirg Proper Shipping Name,Hazard Class,ID,Numcer, 10.Containers 11.Total 12.Lnit 13.Oaste Codas <br /> �q and Packing Group(it any)) No. Type Quantity A't.rvoL <br /> a R!ON4- CNA NA;ZAMCit7L}S WASTE LIQUID 1223 <br /> a (USED OILY WATT R j tU O # t .t. I ®® <br /> rx <br /> LU 2. j <br /> LU <br /> r <br /> n <br /> 3. <br /> i <br /> a <br /> 14.Special Hardl sWct:ons andAdditicnal c Lon <br /> r�diur ctj)propal wPpo <br /> 961-ERG#171 <br /> #"RUli <br /> 15. GENE RATOR'SIO FFE ROR'S CERTIFICATION: I hereby declare that the ecnlenls of this consignment are fully and accprately described abo�v by the proper shipping name,and are classifed,packaced. <br /> madl and lebeledlplazarded,and are in all respects in proper condition for transport according to applicable intemational and national govemmental regulations.If export stupmen'.and I air the Primary <br /> EKpoder, certify That the contents of this consignment conform to the terms or the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minirrrza.ron statement identiW in 40 CPR 262.27(x)(if I am a large goarlity generator)or(b)(H I aria small cvantity generator)is ive. <br /> ereralor era's rmledd yped Name Signature Ilontil ijai ear <br /> r'+ i <br /> J 1o.International Shianants <br /> � ❑import to U.S. ❑Exportfrom U.S. r Portolen !exd:'" `�%'�- <br /> Transoorter si naWre(for exports onl : Dale leaving U.S.: <br /> W 17.Trarspo.Ur Acknowledgment of Receipt of Materials <br /> � Transponk i Printedrryped I a 9� omn ay ear <br /> C Transpoder2 Prrcit yped Name ' <br /> Signature r';y i r. nth Day !Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy ndx:ation Space ❑ Dvandy ❑Type ❑Residue. Q Partial Rejection ❑Fut Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generatcr) U.S.EPA ID Numhar <br /> U <br /> Q <br /> �- Facility's Phone; <br /> w 1Ec.Signahureof.AllernaleFaeiity(orGenerator} l Oxy Year <br /> Z <br /> 19.Ftaza dous Waste Report rlanagement Method Codes(i.e.,codes torhazardous waste treatrr.en%dlsposa(,_and recycling systems; I <br /> w 1 2. <br /> 20.Designate]F Ii Owner or Operator:CertGitatlon of rept of hazardous mater.als davered by the manifeat expect as noted in dam i 8a. <br /> PrintaCJfypedName Sgnature ;' \torte Day Year <br /> EPA Form voo-22;Rev.3a354IRrevibtis eQitfonsare obsolete. TRAPJ�PORTcR' CC <br />