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Please print or hme. (Form desianad for use on elite 112-oitchl tvoewriter 1 <br />Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />2 Page 1 of <br />3 Emergency Response Phone <br />916-849-014401449 <br />. r <br />JJ K <br />WASTE MANIFEST <br />C ALOW329569 <br />5 Generators Name and Mailing Address Generator's Site Address'If dillerenl than mailing address) <br />6" if oad .i brit ter Shap Facility <br />23623 S. Bird Rd. Tracy, CA 95304 <br />510-715-6466 <br />E Transporter 1 Company Name U.S. EPA ID Number - <br />.CRAMENTO WASTE OIL CAL 913 534 912 <br />7 Transporter 2 0mil ny Meme U.S. EPA ID Number <br />8 Designated Fac:il8y Name uta Sile Address U_S, EPA 10 Number <br />21U CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA, LLC <br />2095 Newlands DR. Earn Fernky. NV 98608 <br />775-525-2760 N V D 980 895 338 <br />Fadl.ty's Picone. <br />Sa <br />9b U 5 DOT Description including Proper Shipping Name, Hazard Class,lD Number, <br />10. Contalnars <br />11 Total <br />12. Unit <br />13. Waste Codes <br />No <br />Type <br />HM <br />and Padang Group{dany): <br />Quantity <br />wuw. <br />u <br />' U N 1950 Waste A erosal. Fla m o able N' .O.S <br />L f <br />� <br />0 <br />(AeroaWs Flammable) 2.1 RQ 31 ' <br />z <br />2. <br />w <br />tv <br />3 <br />4. <br />14 ° i JJH `�C' t, u a`4rME D AND USE P P E <br />ERG #126 Proble # 967707-00 �, <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acaxatety described above by the proper shipping name, and aro classified, Packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations If expod shipment and I am the Primary <br />Exporter I certify that the contents of this consignment conform to the terms of the attached EPAAdmawledgment of Consent <br />I certify that the waste m rilmIzation statement identified In 40 CFR 26227(a) (f I am a large quantity generator) or (b) (BI am a small quantify generator) is true. <br />Genera 008erors PdntedlTyped Name Signature Month Day Year <br />� <br />16. International Shipments ❑ n� b U.S. — _ <br />I ❑ Export from U.5 Port of entry/exit --- <br />Z <br />Transporter signature (for exports only): Date leaving U.S <br />IX <br />ednt of Receipt of Materials <br />17 Transporter � <br />a <br />Tren,po��� PrintedlT,�ed N Signature Month Day Year <br />/liD@rt 7�1. 'earnandez <br />ra <br />a <br />QTransporter <br />2 PrintedlTyped Hama Signature Month Day Year <br />18. Disaeparwy <br />18a. Drsaepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number <br />18b Alternate Facility (or Generator) U S. EPA ID Number <br />U <br />Facility's Phone <br />C3&—, <br />ik Signature of Aflemate Fealty (or Generator) <br />Month Day Year <br />Z <br />CD <br />55 <br />19 Hazardous Waste Report Management Method Codes ([a., codes for hazardous waste treabrent, disposal, and recycling systems) <br />UJI G <br />1 <br />2. <br />3. <br />4 <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item I Sa <br />Printed/Typed Name S"tum Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />