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'311-191 5c <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOU�CAL000344637 <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 209-403-7974 006361837 G B F <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> M&L REFRIGERATED <br /> 2323 PORT RD#A <br /> STOCKTON,CA 95205 <br /> Generators Phon209-403-7974 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL,INC. CAR000272302 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS,INC <br /> � MNS000110924 <br /> 8.Designated Facility Name and Site Address <br /> GEM-RANCHO CORDOVA,LLC. U.S.EPA ID Number <br /> 11855 WHITE ROCK RD. CAD980884183 <br /> RANCHO CORDOVA,CA 95742 <br /> Facilitys Phone916-351-0980 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> 1. No. Type Quantity WWol. <br /> w NON-RCRA HAZARDOUS WASTE LIQUID,REFRIGERATN OIL, 1 DM 55 G 221 <br /> AMMONIA <br /> z 2. <br /> CW9 <br /> 3. <br /> 4: <br /> 7t . <br /> {r: <br /> 14°Spedal Handling Instructions and Additional Information <br /> PROFILE# 154975.00 AMMONIA OIL ERG#171 <br /> F. "GENCY CONTACT:DANIEL <br /> �u w <br /> { (MERL1TOR'SIOFFEROR'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 /> a�rkad 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 /> 5 -ter I certify that the contents of this consignment conform to the terms of the attached EPAAcknowled ment of Consent <br /> ty 9 <br /> f rbty ffiat 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)istrue. <br /> Genetators/OBerors Printedrryped Name Signature Month Day Year <br /> 'IrR all <br /> + lJ' <br /> iIto <br /> r 16 fntei a ipmen <br /> I port to U.S. ❑Export from U.S. ort of entry/exit <br /> Tiapsporter signature(for exports only): <br /> „ Date leaving U.S.: <br /> tY 7^1rar"poAcknowled <br /> gment of Receipt of Materials <br /> ' ferlspoaPn yped Name <br /> G Signatur <br /> Mo Day YeA r <br /> T �re P <br /> Name <br /> ,Tl Signature Month ay Y"71- <br /> ear <br /> J7 1 <br /> 18eA[`Taxe i`tN Indlea8on Space <br /> Qu�rttlty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Ica <br /> 18b ANKiiinete, r(or.'Generalor) <br /> Manifest Number. <br /> Facq(tj <br /> U.S.EPA ID Number <br /> jd-, FaciBtys Pftone: <br /> G 1 K 34iialtdre of A temate FadlHy(or Generator) <br /> Month Day Year <br /> 41 <br /> y' 19<Hazardous Waste Report Management Method-Codes P.O.,codes for hazardous(eva8ta treetirtent,disposal,and recycling systems) <br /> G 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 18111 <br /> print ed/T Name Signature <br /> l th DayYearit � 6"a , WhAt -,I AA <br /> '. <br /> EPA Form 8 00-22(Rev.12-17) Previous editions are obsolete. _ :. <br /> DESIG ED FACILITY- EFift,e-MANIFEST SYS*0M <br />