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x <br /> i <br /> Please print or type. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator,ID Number 2.Page-1.11 3.Emergency Response Phone 54.Manifest Tracking Number <br /> WASTE MANIFESTCAL0004453389 1 209-889-1490GBF <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than d cess <br /> FRESH INNOVATIONS CALIFORNIA <br /> 7735 S.HWY 99 <br /> General Pho4.09-689-1490 STOCKTON,CA 95215 <br /> 6.Transporter 1 Company Name <br /> 7.Transporter 2 Company Name AMERICAN VALLEY WASTE OIL,INC. U.S.EPA ID Number <br /> CAR000272302 <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS,INC U.S.EPA ID Number <br /> MNS000110924 <br /> 8.Designated Facility Name and Site Address <br /> GEM-RANCHO CORDOVA, LLC. U.S.EPA ID Number <br /> 11855 WHITE ROCK RD. CAD980884183 <br /> RANCHO CORDOVA,CA 95742 <br /> Fadlltys Phone916-351-0980 <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 0 1' RQ,UN1993,WASTE FLAMMABLE LIQUIDS,N.O.S.,3,Fill 1 DAA 30 G D001 212 <br /> 0 ISOPROPYL ALCOHOL,ETHANOL <br /> w <br /> LLI 2 � -BMS -lis p <br /> Vill <br /> 3. <br /> 4. <br /> 14.Special Handling Instructans and Additional Information <br /> 1. PROFILE#1614368-00 ETHY-GENII ERG#128 3013 <br /> EMERGENCY CONTACT:EVANGELINE <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 International and national governmental regulations.If export shipment and I em the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> a <br /> D Day Year <br /> 16.International hipments C• <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter nature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgmenl of Receipt of Materials <br /> � Transporter 1 yped N e <br /> 00 -re Month Day Ye <br /> z er Pn le ed NAWIC <br /> Month Day Ye <br /> 18.Discrepancy 10 X <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) <br /> Manifest Reference Number. <br /> r U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> Lo 18c.Signature of Allemate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 `n 2. 3. <br /> 11h"f` 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest pt noted in Item 18a <br /> Printed/Typed Name Sign e <br /> LlMonth lay, Y <br /> EPA Form 8100-22(Rev.12-17) Previous editions are obsolete. SIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />