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Form.Approved,OMB No.2050-0039 <br /> Please print or type. 4.Manifest Trackin Number <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone g G B F <br /> UNIFORM HAZARDOUS CAL000035904 1 209-239-1361 <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Site Address(ff different Than mailing address) <br /> TUFF BOY, INC. <br /> 5151 E ALMONDWOOD DRIVE <br /> MANTECA,CA 95337 <br /> Generators Phor209-739-1361 U.S.EPA ID Number <br /> 6.Transporter 1 Company Name CAR000272302 <br /> AMERICAN VALLEY WASTE OIL,INC. <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name MNS000110924 <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS,INC <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address GEM-RANCHO CORDOVA. LLC. CAD980884183 <br /> 11855 WHITE ROCK RD. <br /> RANCHO CORDOVA,CA 95742 <br /> 816-351-0980 <br /> Fadlily's Phone. <br /> 9b.U.S.DOT Descrip8on(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> ga No, Type Quantity WtNol. <br /> HM and Packing Group(if any)) <br /> X 1 RQ,NA1993,WASTE COMBUSTIBLE LIQUID,N.O.S.,COMBUSTIBLE 1 DM 55 G D001 331 <br /> LIQUID,PGIII <br /> z 2- <br /> w <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Addit onat Information <br /> PROFILE#1614228-00 DIESEL ERG#128 <br /> EMERGENCY CONTACT:MARTIN <br /> 15. GENERATOWSIOFFEROR'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 am the Primary <br /> Exporter,I certify that the contents of this consignment oonform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)pf I am a large quantity generator)or(b)(if I am a small quantity enerator)is true. Month Day Year <br /> Gene <br /> rator's' s Printedrfyped Na Slgnatur <br /> Iipments ❑Import to U.S. ❑Export from U.S. P rt of entrylexit: <br /> i— Date leaving U.S.: <br /> ? Transporter signature(for exports only): <br /> W 17.TransporterAcknowledgment of Receipt of Materials Mo th Da Year <br /> TransporIVI Printed/Typed Name a <br /> IL Month ay Yea <br /> Tra n /Typed NamS <br /> 18.Discrepancy <br /> cation Space El Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18a.Discrepancy Ind! <br /> ❑ Quantity El <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> J <br /> U <br /> 11 Facility's Phone: Month Day Year <br /> In <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 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 Month Day Year' <br /> Printed[Typed Name Signature ` <br /> VIA AO <br /> EPA Form 8700-22(Rev.1217) revious editions are obsolete. DESIG TED FACILffY TO EPA's e-MANIFEST YSTEM <br />