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N► N <br /> Please print or type.(Form designed for use on elile 12 itch) ewritec) Foran Approved.OMB No.2050439 <br /> 1. enemlur ID Number 2 Page 1( 3.Emergency Response Phone 4.Mardfesl Trackin Number <br /> UNIFORM HAZARDOUS e^iQo03ZS�e7 1 916-849-0144 012418465 JJK <br /> WASTE MANIFEST <br /> 5.Generuton's Nana and Mailing Wrens �� �+ g r Generzlo/s SileAddress(ddifrevent than ma&ng address) <br /> J{lirrinlgtJx c 'd. Z. j d S <br /> Genualm'sPhone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SACRAMENTO WASTE OIL CAL 913 534 912 <br /> 7.Transporier 2 Company Name U.S,EPA ID Number <br /> B.Desi uated FacialName and SiteAddress U.S.EPA ID Number <br /> 71gr3t '%N8 URY ENVIRONMENTAL MANAGEMENT OF NEVADA, LLC <br /> 2195 NEWLANDS DR, EAST YERNLEY, NV 98408 NVD 980 895 336 <br /> Facilitys Plane: 775-525-2760 <br /> 9a 91b.U.S.DOT Description(i dudmg Proper SMppi g Nam,Hazard Cess,ID Narben 10.Owns Irs It,Total 12,Unit 13.Waste Codes <br /> HM and Paddng Group(d any)) No. Type Quantity "No. <br /> 1. ON—RCA HAZARDOUS WASTE SOLIDS Pc 3 <br /> ( OILY SOLIDS ) <br /> z.(til✓51 A !4 o x ` urs 19 So � 1 <br /> 3. <br /> 4. <br /> T-7 <br /> 14.5 al Handla��Instructions and AWiOmal In to abort <br /> EYeANDLEKS TO BE TRAIN'S AND USE PPE <br /> ERG ® 128 1 PROFILE ¢ 447190-02 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hembydedam that the contents (this consignment are fully and accurately described above by the properldpping name,and are classiled,packaged, <br /> marked and labeled/plaanded,and are in all respects in proper con iiii,far bmmixorl according to appfiable international and national governmental regulafions.If export shipment and I am the Pmnary <br /> Exporter,l only mat the comers of the consgnmml conform to the temp of the affected EPAAcknoMedgnenl of Consent. f <br /> I cortty that the waste minimization slaternent klentfied it 40 CFR 26227(3)(d Icon a large quantity generator)or(b)It I am a small quantity generalm)is true. <br /> Gara>•atdsCliemes Pnmedilyped Name Signature Mona Day Year <br /> —1 16.International Shipments ❑import w U.S. ❑Export from U.S. Portofeney/exit <br /> Tiallsoorler signature(ror exports arty$ Date ksaang U.S,: <br /> 17.TransporlerAcknoWedgme(o(Receipt of Materials <br /> tE Transporter I Print/edlTyped NJ Signature Month Day Year <br /> re <br /> 2 Printecitryped Name Signature Month Day Year <br /> } 18.Discrepancy <br /> 18a.Discrepancy Illation Spam ❑ Quantity ❑Type ❑Residue Partial Refedion Fut Re <br /> o <br /> Manifest Reference Number. <br /> 18b.Atemate Facility(a Generator) U S.EPA ID Number <br /> J <br /> v <br /> LL FadkNs Phone: <br /> 8 18c Signature ofAllwnate Facility(or Generator) Month Day Year <br /> Q <br /> x <br /> a—i 19.Hazardous Waste Report Management Me"Codes @.e.,codes fa harardouswastemealment,ls recycingsystems) <br /> 1. 2, 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous mmsrials covered by the manifest except as ruled in Item 18a <br /> 111 Printecirryped Name tiNnature Month Day year <br /> EPA Form 8700-22(Rw..3.05) Previous edifions are obsolete. GENERATOR'S INITIAL COPY <br />