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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) !! Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTCALf 1 [09-334-3396 003529518 G B F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ACME SAW&SUPPLY•LODI <br /> 114 N. bAt,1 Wt:N'ttl ti5t <br /> L00i,CA "^_240 <br /> Generator's Phont_334--3396 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL,INC. CARWO272302 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS, INC. MNS000110924 <br /> 8.Designated'F6icility Namethd Site Address U.S.EPA ID Number <br /> CHEMICAL RECLAMATION SVCS T7CDd4f3E144700 <br /> 406 POWELL STREET <br /> AVALON,TX 713823 <br /> Facility's Phona�72-827-3224 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> X 1. RQ,UN1993 WASTE FLAMMABLE,LIQUIDS,N.O.S.,3,PGII, 1 UM 56 G 0001 D018 331 <br /> o GASOLINE,OIL C)U1S ##H <br /> z 2. <br /> L <br /> t9 <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> PROFILE#915306-00 GiAS&OIL ER(0128 <br /> EMERGENCY CONTACT': JOHN <br /> 15. GENERATOR'S/OFFEROR'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 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 /> Generator's/0;roes Printed/Typed ame Signature Month /Day Y ar <br /> J 16.International'Shipments <br /> Z ❑Import to U.S. ❑Export from(u.S.,, Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Tra obi 1 Pdnted/Ted Name Sig Month Day Y ar <br /> 7 4 <br /> ZTranspo er 2 Printed/T Name Si nature <br /> 9 � Month Day Year <br /> � 1 � <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.H zardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 \\W_ 12, 3. 4. <br /> :20.Designated Facility Owner or Oper tor:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pri t d7T ped Nam� ' I i ignature { ', I Month Day Year <br /> EPA Form 700-22(Rev.3-05) Previous editions are obsolete. <br /> n1=Q12AlATPn CAf'll ITVTr%f_=h1CDATn0 <br />