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10/06/2014 01:49 FAX <br />Slate of Coll fornlo—Envlran men toI Peoteelian Apeney <br />Form Approved OMB No. 2050.0039 (Expires 9 30-991 See Instructions on bock of page 6, <br />Please print or type. Form designad for use on elite (12-pirch) rypewrPor, <br />Lee <br />n <br />h <br />sn <br />W <br />0 <br />0 <br />©_ <br />N <br />aL <br />0 <br />a <br />V <br />z <br />w <br />w <br />X <br />W <br />0 <br />w <br />N <br />a <br />U <br />ii <br />1A 001/001 <br />Deportment of Toxic Substances Cartrol <br />Sacramento California <br />DO NOT WRITE BELOW THIS LINE. <br />DISC 6022A 1 9) Blur-- GENCRAjOR SENDS TH15 COPY TO DTSC wITHIN 30 DAYS. <br />EPA 870 22 To: P.O. Box 400, Sacramento, CA 95912.0400 <br />UNIFORM HAZARDOUS <br />1 Generator's US EPA Ip No, Manifest Document No.2. <br />Page 1 <br />Information in tke shaded areas <br />WASTE MANIFEST <br />L U Q �� 3 Q (y S Zof <br />is not required by Federal low, <br />3. Generator's Name and Mailing AddreltIQ (s'l„�,Cr flw <br />J1 j-tL) <br />A. Slala Mani Fosr Deaumen! Number 2 3 7 7 4 5 ,.,, �.,� <br />3 <br />�M �Q <br />�/� <br />V <br />B. State Generator's tD <br />Q l , `� <br />A Generator's Phona�09s6J.3. q -�75 f•,•Od 1 (A, �5a1-)(� <br />5 Troniperler 1 Company Name 6. US EPA ID Number <br />C. Stale Transporter's ID [Reserved.) <br />AMERICAN VALLEY WASTE 0!L t- . 1 n Q QA a 7 R 7 � <br />D, Transporter's Pkona MCC <br />.., .�, <br />7. Transporter 2 Company Name 6. US EPA ID Number <br />E, Stole Tronsporler's ID [Reserved.] <br />F. Twipdrter's Phone <br />9 I�'�Yir'1���1s1 ilAFl� 10. US EPA ID Number <br />G. Staleecik'sLD 0 0 0 1 g 0 S 1 6 <br />5300 CLAUS ROAD <br />RIVERBANK, CA 95367 I C G 0 1$ <br />H, Facility���$3�489 <br />11. US OCT Doseription (including Peeper Shipping Noma, Hazard Class, and ID Nymber) <br />12. Canlainers <br />13. Total <br />14 Unir <br />No. <br />Type <br />Ouonlity <br />WI/vol <br />I. Wasro Nymbor <br />°. NON-RCRA HAZARDOUS WASTE LIQUID <br />Stele 221 <br />d OILY WATER) <br />0 0 <br />T T^a <br />EPA/other � <br />(, <br />Nb. <br />Store - <br />E <br />_ <br />R <br />EPA/Other <br />T <br />`' <br />Stole <br />0 <br />EPA/Other <br />R <br />d' <br />State <br />EPA/Otker <br />J. Additional Descriptions For Materials Hilad Above <br />K, Nemciling Codes for Wastes Listed Above <br />OILY WATER <br />a, 01 6. <br />c. <br />d. <br />15, Special Handling Instructions and Additional Information S Ja 1 J L , e 1 <br />GLOVES <br />EMERGENCY PHONE 209-667-8857 LQ(�f C c�2-L4o <br />16. GENERATOR'S CERTIFICATION; I hereby declare that Ike contents of this consignment are fully and accurately described above by proper shipping name and are clmsified, pocked, <br />marked, and labeled, and are In all eaepeels in proper condition for reansporl by highway according to applicable international and notional ragulolions. <br />go•ernmoni <br />If 1 am a large quantity generator, I eorriiy That I have a program in place to reduce Ike volume and toxicity of waste generated la the degree I hove determined to be ewnomleally <br />practicable ord Thor I have selected Ike method a treorinenI slorage, or disposal to fuTure <br />practicable cy(renrly a•oilo6le me which minimizee the present and threat to human health <br />and the environment; OR, if I am o small 9u0nrity geneeotor, I have made a good follh effoer to minimize my waste generalion and select rho best wolte management method lhor is <br />available to me and that I con afford <br />Prinrod/Typedjl�oma <br />C�l/'rL•�' �C� '�'c' <br />Slgndlure :' <br />Day Year <br />c <br />` ' ' i 2 <br />fl'i`.f➢.s... �-t , r, � �, <br />l�Month <br />lJ t� � �� <br />A17, <br />Trane rte, 1 Acknowlod omens of Receipt Moterials -- <br />p <br />Prinrod/Typed Name <br />Signatures <br />Monrh Day Year <br />'i <br />0 <br />i B, Trans orrer 2 Acknowled amen, of Re 1 of Materials <br />R <br />T <br />Prinled/T ed Noma <br />yp <br />Sign°lure Month Da Year <br />y <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />20, Foc;lily Owner or Operator Ceellfie°lion of receipt of hazardous molarials covered by this manlfesl excai3i as norod in hem 19 <br />r <br />Printed/Typed Noma <br />Signature <br />Month Day Year <br />Y <br />1 <br />DO NOT WRITE BELOW THIS LINE. <br />DISC 6022A 1 9) Blur-- GENCRAjOR SENDS TH15 COPY TO DTSC wITHIN 30 DAYS. <br />EPA 870 22 To: P.O. Box 400, Sacramento, CA 95912.0400 <br />