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S <br /> i <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOl15 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST `ALOf;7:3�3 1 91t3� �di3-75&l 0 y F,3 `2117 GBF <br /> 5,Generator's Name and Mailing Addra AA-I_`ANTIC AVIATION Generator's Site Address(if different than mailing address) <br /> 6652 PINECREST DR SUITE#300 6364 S.LINDBERGH ST <br /> PLANO, TX 75024 SfOCKTON CA 96206 <br /> 14"16-2W7580 <br /> Generato>'s Phon : <br /> 1 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEYWASTE OIL, INC_ CAR000272302 <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> S`= STERICYCLE SPECIALTY WASTE SOL"ONS,INC IvNSODUI10924 <br /> 8.Designated Facility Name and Site AddressGEM-RANCHO CORDOVlA, LLC- U.S.EPA la Number <br /> 11865 LIVf-19TE BOGY.RT?. - <br /> CAf.7$80884183 <br /> RANCHO COR DOVA,CA 8574 — <br /> Facility's Phone 1�- $1-99$LJ <br /> ga, 9b.U.S:DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> X 1. RQ,UN1863,WASTE FEUL,AVI[ATION,-fAJRBINE ENGINE,3, Ill 1, 3 M 13.5 G D001 331 <br /> or KEROSENE',OIL <br /> a <br /> 2. <br /> r.0 <br /> C7 <br /> 3. <br /> I 3 <br /> 4 i <br /> 14.Special Handling instructions and Additional Information <br /> 101,19976-00 JE-T-FLIEL ERC 128 <br /> EMERGENCY CONTACT'GEOFF <br /> 15. GENERATOR'S10FFEROR'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 labeledlplacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 Cl 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true, <br /> Generator`slOfferoi's P'ntedfTyped Name Signature Month Day Year <br /> —Te-Tv, 6=�6 <br /> 16:International Shipments. ❑Import to US. Export frcr/ Porof en(ry)ex <br /> it: <br /> ? Transporter signature(far exports only): Date leaving U.S.: <br /> tY 17.TransporterAcknewledgmenlofReceipt ofMaterials <br /> 11:! <br /> Transpoder�,' dfTyped Name Signat Month Day Y ar <br /> CL <br /> .!� <br /> Z Tra over 2 rintod ed Name Signature h "Day Year <br /> 0a <br /> i'- <br /> H- <br /> 18.Discrepancy <br /> ❑Type <br /> ❑ Quantity 71 Residue El Partial Rejection ❑Ful!Rejection <br /> -18a:Discrepancy indication Space <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> 0 <br /> Facility's Phone: ti <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> W 141 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PrinledfTyped IN Signature Month Day Year <br /> 2 1691 Ig <br /> EPA Form 8700-22(Rev.12-17) Previous editions are o solete. DESIGNATED FACILITYTO GENERATOR <br />