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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000267135 1 209-499-2693 002739465 GBF 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) EMILS LIQUORS&SPORTS SHOP 1406 CALIFORNIAST ESCALON,CA 95320 Generator's Phone:209-838-7674 6.Transporter 1 Company Name U.S.EPA ID Number AMERICAN VALLEYWASTE OIL,INC. CAL000827878 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 21CENTURY ENVIRONMENTAL MGMT OF NEVADA,LLC U.S.EPA ID Number NVD980895338 2016 NEWLANDS DR.EAST FERNLEY,NV 89408 775-575-2760 - Facility's Phone: _ ga 9b.U.S.DOT Description(nciuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1 RO,UN1203.WASTE GASOLINE,3, PGII 1 5 G D001 DO18` 213 oAGED GASOLINE a Z 2. LU IL 3. i UN 1 5 2015' .MVV - T 14.Specai Hand inc Irs`sctions and Additional Information PROFILE# 7Z?5167~cV AGED GASOLINE,ERG#128 CONTACT; PAM 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descdbed above by the proper shipping name,and are classified,packaged, 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 am the Primary Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity general b)(if I am a small quantity gene r)is true. nature,;;n-p�A79- :5= Month Day Year Ge s/0� sePrilted/Typ d Name�� 9 P ( � -j 16.International Shipments 1. ❑Import to U.S. El Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials UJ Transporter 1 Printed/Typed Name Signature ZMonth Day Year Z Transporter Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b,Altemate Facility(or Generetor) U.S.EPA ID Number J U LL Facility's Phone: Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ) 'DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)