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1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-003! <br /> UNIFORM HAZARDOUS 1.Generator ID Number `- 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ��\(-0c0 3)(C&CG I 1 916-849-0144 012478938 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> LL-c_ D'34 .AII4,' -z*i <br /> 14v)4 J�►'. Jt .l�1va GIS, 520-7 <br /> Generators Phone: Z0 1 - 'I q 3 - ZS <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SACRAMENTO WASTE OIL CAL 913 534 912 <br /> j7.Transporter 2 Company Name U.S.EPA ID Number <br /> n <br /> D 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21st CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA, LLC <br /> 2095 NEWLANDS DR. EAST FERNLEY, NV 98408 NVD 980 895 338 <br /> Facility's Phone: 775-525-2760 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Containers <br /> 11.Total 12.Unit <br /> a HM and Packing Group(if any)) Quantity 13.Waste Codes <br /> � No. Type y Wt.Nol. <br /> 1 352 <br /> v o NON -RCRA HAZARDOUS WATE SOLIDS �- �/� ) 00 p <br /> M ( OIL SOLIDS ) <br /> W <br /> v Z 2. <br /> W <br /> = C7 <br /> S <br /> v 3. <br /> U <br /> G <br /> 0 <br /> FEB 2 5 2016 <br /> 4. <br /> ENVIRONMENTAL HEALTH <br /> PERMIPSERVICES <br /> i 14.Special Handling Instructions and Additional Information <br /> 3 HANDLERS TO BE TRAINED AND USE PPE <br /> a <br /> ERG 'A 128 PROFILE <br /> 15. GEN ERATOR'S'OFFEROR'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 /> mar e,:a--labs e�placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> c <br /> -e f;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 small quantity generator)is true. <br /> Generators,Offeror's Printed/Typed Name Signature Month Day Year <br /> 1�• <br /> I -J 16.International Shipments <br /> t= ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pri ledffyped Name Signature Month Day Year <br /> r f <br /> Y I �-f 12 :6 <br /> i ZZ Transporter 2 Printed/Typed Name Signa ure Month Day Year <br /> s <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityType❑ yp El 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 /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />