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<br /> Please print Or type. Form Approved,OMB No,2050.0039
<br /> UNIFORM HAZARDOUS 1.GenemtorlD Number 2.Page 1 of 3,Emergency Response Phone 4,Man llost Tracking Number
<br /> WASTE MANIFEST CAL00003 209-13143891
<br /> 021823792 J J I T
<br /> 1 s
<br /> 6.Goneialor's Name and Mailing Address V
<br /> Generators Site Address(if different than mailing address)
<br /> MADRUGA IRONWORKS
<br /> 305 GANDY DANCER DR. 6
<br /> TRACY,CA 95376
<br /> Generator's Phon2OM32.7003-105
<br /> 6.Transporter 1 Qompany Name U,S,EPA ID Number , !'
<br /> AMERICAN VALLEY WASTE OIL,INC, CAR000272302
<br /> 7.Transporter2 Company Name (�
<br /> STERICYCLE SPECIALTY WASTE SOLUTIONS,INC U.S,EPA ID Number
<br /> MNS000110924 •
<br /> 8,Designated Facility NO end S(teAddress U.S.EPA ID Number
<br /> 21 ST CENTURY
<br /> ENVIRONMENTAL MGMT OF NEVADA,LLC
<br /> 209.6 NEWLAND$DR.EAST NUD98n$9b338
<br /> FERNLEY,NV 89408
<br /> FaciliVs Phone770-576-2700
<br /> 9a, 9b,U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers
<br /> HM and Pacing Group(t any)) 11,Total 12,Unit 13.Waste Codes
<br /> No, Type Quantity WLNo1,
<br /> 0 1-'NON-RCRA HAZARDOUS WASTE LIQUID,COOLANT,SILICONE OIL 3 DIV! igg G 221
<br /> tz 2,
<br /> 4.
<br /> 14.Special Handling hisUucuons andAddillonai infonnatioh
<br /> PROFILE# 709213-03 MACHINE COOLANT ERG*171
<br /> EM9RGENCY'CONTACT.JOSEPH
<br /> 16. GENERATORS/0"ER611%CERTIFICATION:,I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,Ord are classified,packaged,
<br /> marked and labeled/placarded,and aro in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.Ifexport shipment and I am the Primary
<br /> Exporter,I certify that the cohtsnlsof this consignment conform to the terms of the attached EPAAcknowiedgmenl of Consent.
<br /> I cerdfy,that the waste minimization siatemanl Identified in 40 CFR 262.27(8)(if t,am a large quanetygenerator )or small quetilily generator)Is we.
<br /> Ge,'nei' is Pdnte'dlTyped Nema Sip re •
<br /> wnnt'h Day Year
<br /> z;r 16.Wrilallonal Sh1prw4s
<br /> LJ Import to U.S. L,..t
<br /> Transporlerslg �—t Export from us. Po
<br /> nalura(tor exports only); patrtofentryle leaving Uexfl:.S.:
<br /> 0.W' 17,TranspoderAckrowledgment of Receipt of Materials
<br /> Jai Tran9porter 1 dnted/IWed Name signature
<br /> Month Day Year
<br /> Trans Pdq a ype Name Signa
<br /> M Day Y ar
<br /> t-
<br /> 18,Discrepancy
<br /> 18a,Discrepancy indication Space Quantity T
<br /> ❑Residuo ❑Parlial Rejection ❑Full Rejection
<br /> 18b.AltematO Facility(or Generator) Menlieat Reference Number:
<br /> U.S.EPA ID Number !
<br /> C)
<br /> LL Fadlityis Phone:
<br /> lao,Stgnahrre OfAllem8w Facltly(or G@nerator) y
<br /> Mould Daq, Year
<br /> t
<br /> 19,Hazardous Waste Report Managemegl Method Codes(i.e.,trades for hazardous weste treatment,disposal,and recycling systems)
<br /> 4.
<br /> 20.Doytgneied Fadtuyqwneror operator:certiecation of recelpt of haze offs materials covered bwlivinanifest except as noted In If m 18a
<br /> thintearrypad Name . ,- dire Month ay Year
<br /> "It,14
<br /> r
<br /> EPA Form 8700-22(Rev,* - ) PrSviaus It
<br /> DESIGNA• I" I TO EPA's 0 NIAWMST SYSTEM
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