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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.Pa 1 of 3.Emergency�Respon_se Phone 4.Manifest Tracking Number <br /> t WASTE MANIFEST CALOOM1216 208.825-0 <br /> ,t 4; 003732289.' G B F <br /> ,,. 5.Generator's Name and Mailing Addres _ Generator's Site Address(if different than mailing address) <br /> biLL:S MOWER a 6AW MANTECA <br /> 852 N.MAIN ST. lF <br /> MANTIaCA;CA 95338 <br /> 209-825-020 +: <br /> a. Generator's Phone: w +:, •,, <br /> t"+ 6.Transporter 1 Company Name ".-?++' b. t U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL',INC. CAR000272302 <br /> 7.Transporter 2 Company Name r U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS,INC MNS000110924 <br /> t <br /> 8.Designated Facility Name and Site AddressCHEMICAL RECLAMATION SVCS U.S.EPA ID Number <br /> 405 POWELL STREET TXD048844700 <br /> t ' t AVALON,TX 78823 <br /> 4214-627-3224 <br /> f Facility's Phone: a' <br /> Lpr 9b.U.S.DOT Description(including Proper hipping Name,Hazard ass,ID Number, 10.Contaers 11.Total 12.Unit13.Waste Codes <br /> ) <br /> 9a. .' <br /> c HM and Packing Group(if any))• No. Type Quantity SNHClbinWtJVaI. <br /> 1• RQ,UAd1993,WASTE FLAMMABLE LIQUIDS,N.O.S.,3,PGII, 1 OM 55 G <br /> o GASOLINE,OIL ' ' cm ITS 211 N <br /> us `4G: W <br /> LU <br /> <ra- is 3. d of. J 1 <br /> 4. <br /> 1 <br /> r� t 14. c tt�it n��linnQQ nstructio.Dsand Additional•Information <br /> �FI�EiF 87-001 AGEOGAS ERG#128 <br /> EMERGENCY CONTACT:CRAIG <br /> ! 15. GENERATOR'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 dassified,,pai kaged;°., >? <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°7a'' kTt' <br /> 1. ,,•� t <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 /> F! <br /> Generato?slOfferor'sPnntedlTypecl jilame r `.Signature Month, a Day Year- <br /> -� 16.International Shipments ❑ ❑ : ' }�;' <br /> h- Import to U.S. Export from U.S. Port trylexit <br /> z Transporter signature(far eitports•only):- Date leaving U.S.: <br /> "k , <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> a, <br /> Tran to Name gn r .Mont' Da Yea. <br /> O <br /> CL a l: <br /> Qan port 2'nn ed7Typed Na a Signatur "!" Mo ay _ Y r <br /> r �' q , <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space1 <br /> ❑ Quantity ❑Type El ❑Partial Rejection ❑Full Rejection• -' <br /> ! Manifest Reference Number.• !t, <br /> 18b.Alternate Facility(or Generator) ! U'.S`EPA ID Number <br /> s,•' U- Facility'sPhune. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day, <br /> Year <br /> Q <br /> H19.Hazardous Waste Report Management Method Codes(i.e:,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. 0 1 2. 3. 4. <br /> 20.Designa d F cility Owner or Operator:Certification of receipt of hazardous materials covered by the.manifest e e t as noted in Item 18a <br /> Printed/Typ N e Sign tur s <br /> MU (DQ <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. z. ' <br /> ATED FACILITY TO GENERATORSTATrE,I�IF.REQUIFED) <br /> , , Jt <br /> r -, <br /> 1 <br />