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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000445389 209-689-1490 U B F <br /> 5.Generator's Name and Mailing Address Generalor's Site Address(if different than mailin a ress v <br /> FRESH INNOVATIONS CALIFORNIA <br /> 7735 S. HWY 99 <br /> STOCKTON,CA 95215 <br /> Generators Phon?.09-689-1490 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY(WASTE OIL, INC. CAR000272302 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS, INC MNS000110924 <br /> 8.Designated Facility Name and Site Address 21 ST CENTURY ENVIRONMENTAL MGMT OF NEVADA,LLC U.S.EPA ID Number �\ <br /> 2095 NEWT ANDS DR. EAST NVD980895338 <br /> FERNLEY,NV 89408 <br /> Facility's Phone775-575-2760 <br /> ga gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> X 1. <br /> r? 2. 4,WASTE SODIUM HYDROXIDE SOLUTION,8, PGII 1 DF 5 G-1 D002 122 <br /> c� <br /> i <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 2. PROFILE#1614370-00 SODIUM HYDROXIDE ERG#154 <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 Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental 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 EPA Acknowledgment 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 small quantity generator)is true. <br /> Generators/Offeror's Pnnted[Typed[Jame � SippAre � J Month Day Year <br /> 16.Intematlonj Shipments v <br /> F-- ❑Impart to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter P /Typ d ame Signatur -D Month Day Year <br /> O / !/ <br /> CL <br /> Z Trarepyer 2 PrinredlTypedNannev i e <br /> M nth Day r <br /> UCX <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.A.Itemale Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> u`t Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> vi19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q 2. 3. 4. <br /> 20.Designated hicility,Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as notegin Item 18a <br /> Printed(Typed Name Sig ure 7 Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editionsar obsolete. /�. , <br />