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Please print or e. Form desi ped for use on elite 12- itch ewriter. JApproved.OMB No.2050-0039 <br /> P YP l 9 ( P )�P ) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.ManifestTrackin Number <br /> WASTE MANIFEST CAL00035OW � � : OU,����-490 G B F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Mill STREET ARCO AM-PM <br /> 1'100 S.MAIN STREET <br /> MANTECA,CA x5337 <br /> Generator's Phon2O9-825-6 7 84-'105 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL,INC. CARO=7230R <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS, INC 144SM0110924 <br /> 8.Designated Facility.Name and Site Address _.. .-.._ U.S.EPA ID Number . <br /> CHEMICAL RECLAMATION SVCS TXM46844700 <br /> 405 POWELL STREET <br /> AVALON,T'•G 76CM <br /> Facility's Phoney•1 . _ 2)• <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt/Vol. <br /> O X 1. i3f)q I D018 331 <br /> RCS;l./N12S.1l <br /> �,WASTE PETR .El.IM DI�,TII:i-AYES,N,0.19-3, PGI), 1 [1M 55 <br /> GA.c ?LIll DIESEL - CEJ V, OUT-S 211H <br /> z 2. <br /> w <br /> �(� r 5 753 <br /> JN\Ilt �tZ1 <br /> MIE <br /> 14.Special Handling Instructions and Additional Information <br /> PROFILE# 791371-01 WATER,Gila El i 6 <br /> t MERGENCY CONTIiCT: ,IASBIR <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable ihtemational and nationalgovemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a all quantity generator)is true. <br /> 7/Offeror's PrintedFryped Name Signature ' Month, Day Year <br /> -� 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> Liu 17.Transporter Acknowledgment of Receipt of Materials <br /> Of Tran er-1 Printe/T d Name 4r - Month Day Year <br /> O <br /> d <br /> Z ra s er 2'PfifitedMame 41 Signature —Month Day <br /> t- <br /> 18.Di crepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> < Facility's Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Qi <br /> Z <br /> 2 19.Haz dous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and"ecycling systems) <br /> 0 1 2. 3.. 4. <br /> Dmf .1 <br /> 20 Des Hated Facility Owner or Operator:Certifi ' <br /> ca on of receipt of hazardous materials covered by the manif a pt as noted' 4gm 18a <br /> Ll ( 7 "'E C —C- <br /> Prime y ed Name nt <br /> EPA Form 8700-22(Rev.3-05) Previous edltio re.obsolete. l <br /> DESIGNATED FACILITY TO GENERATOR <br />