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Please print or type-{Form designed for use on elite(12-pitch)lMGMArl er.) <br /> Fonn Approved,OMB No.20500039. <br /> 1. ror ID Number 2.?age 1 of 7.Emergenry Response Phone -4.Manifes[TraeNing Number G B F <br /> UNIFORM HAZARDOUS Genera3434506 <br /> WASTE MANIFESTC gOfl 1 209-131 u <br /> 5 Generators Name aria i Address GeeammlS Site Address€>f diderenithan mating address) <br /> SANGUiFd>I INVEb-TMENrS LLC <br /> i E638 COPPEROPOUS RD 4469 S.ESGALONE SFLLOTA RD <br /> LIUtfV,CA '36236 FARMINGTON.CA 95230 <br /> Generators Phe i1.5.EPA ID Number <br /> 6.7ranspoder 1 Company Name CAR0002723CY2 <br /> vMERICAN VALLEY WASTE OIL,1140 <br /> U.S.EPAtO Number <br /> 7.Transporter 2 Company Name <br /> STERICYCLE SPECIALI Y 41rASTE SOLUTIONS,INCmi 10924 <br /> U-$.EPAIDNumber <br /> 8.Designated fadlity Name and Ste Address <br /> 215'1 CENTURY ENVIRONMENTAL rvlGiulT OF NEVADA,LLC NVD880895338 <br /> -095 NEWLANDS DR.EAST _ <br /> FERNLEY,MV 89408 - <br /> Facdily's Phone775-5752760 <br /> t0.Containers13.waste Godes <br /> 9a. l}-5.DOTUesaipticet lindutling Proper 51Uppng Name,Hazard.Cfass.kUNwnbe'. tryIT12 <br /> HM and Parking G"V any)) No. Type . <br /> X 1.W077 HAZARDOUS WASTE SOLID,N.O.S.,9,PGIII,GASOLINE& 1 DM 24U P D018 352 <br /> C D€i PUMP FILTERS&HOSES <br /> i 2 <br /> ca <br /> w.,... _.._.._.,.. .... <br /> 3. <br /> s <br /> 1 <br /> t <br /> 4. <br /> 14.Spec',al Handtmg[.ructions and Addifionel Informe[lon <br /> PROFILi 7586811 GASOL€NE&DIESELPUh'IPFILTERS ERG#171 <br /> EMERGENCY CONTACT,RON <br /> 1E. GENERATOR'SIOFFEROR'SCERTWICATWN:(hereby dedare[hal the conlerls Wlhis consignment are fully andaccur Wydes[ihed above by the proper shit borrow and amalessilied,packages. <br /> mancedand Iaheledlplacarded,and are M M respects m prcwtuardi ion!orbansport according to applicable kdemar'wraland national govammental regulations.bespotl ship-rd and I am the Rimary <br /> Exporter.I mf*that me contents of this consignment=drn,to the wens,of the attached EPAAckrm6idgri of Comenl. <br /> l retry that tha waste mininization statement identified x 40 CFR 21 if I am a large qt nfky generalarl or(b)tC am a small gtzaraity generator)is true. <br /> Generatoeat(Nfemrsred Name Signature Month Day Year, <br /> 'C LS tf5 11-7 <br /> 18.Irdematiwial S-mems ❑11 1.U S_ ❑Expod from US- PORM exie. <br /> Trampi signature{fta ev"or[ly): Data ki. D.S.: <br /> 17.Transp",AcknoNEe Fwd of Receipt of ferials. <br /> Transporter i Pdrt�Oeyped Nam Signature ,r 1 lAonth NY Year <br /> a <br /> QTransporter 2Pn. Nryped Ne Signature month Day Year <br /> GC <br /> M <br /> i8.0iscrepar,y <br /> 1$a.Dearipancyindcak.$pace ❑Duantlty ❑Type ❑Residue ❑Partial Rejection ❑Full Refeclim <br /> Manifest Reference Humber <br /> Fadfiry€m Gen is ata U.S.EPA ID Number <br /> 186.tilarnale I <br /> U <br /> LL Ni Phone. <br /> 18c.Signal—ofAtlernola FacrRy(or Generatar) IAon1h Day Year <br /> r <br /> a <br /> z <br /> rn <br /> 19.Hazardi Waste Report Managemerr Medtdd Cordes(i.e.,codes twhazardaus waste trearmariiosat and re yding systems) <br /> 20.Dedgnatad Facaity Owner oc Operator'.CecRpcadon of receipt of hazardous materials—ered>y the manifest except d in Item 18a <br /> PnntedlTyped Name Signature i th Day yew <br /> 7 <br /> EPA Farm 8700-22(Re Ffevii editions are obs tele. p� y( <br /> [}ESI AT7,f��r�DE5T€NATION STAT�,g!�'�)!'F� <br />