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06 / 11 / 2021 1 : 48 Pili FAX 2099488625 AHCE SAW 0401 / 0002
<br /> • Please print or type. (Form designed for use on elite (12 pitch) eWritec) Form Approved, OMB No, 2050.00$6
<br /> UNIFORM HAZARDOUS 1 ' Generalor ID Number 2, Pagre 1�L06746"
<br /> argengy Response Phone 4, Manifest Tracking Num or �t
<br /> WASTE MANIFEST CAL006178438 1 •iQ9 "1 D
<br /> 54Genaratgr g Nacos and Melting Address 68neretoes Site Address Of different than malling address)
<br /> ACIVIVSAW
<br /> 1204 F MAIN 8T
<br /> %STT :KTW CA 95205
<br /> Generator's Phony ' rte, ,- G ',
<br /> 6. Transporter 1 Company Name U,S, EISA ID Number
<br /> AMIERICNt-4 VALUEY MSTE OIL, INC . CARU0027�3p2
<br /> "T Transporter 2 Company Name U,S, EPA9D Numbor
<br /> $I"EKICYCLL SPE" C)AL7•Y WASTE tiiULUYIbN!3 IN(; MNS000110924
<br /> 8;DeSignstsd Feclity Name and Site Address U,S: EPA Ip Number
<br /> OMMIGAL MC ILAM 't 1061 Svc:
<br /> 405 Fk)VUEInt, `,,`7171~1;f "rx.D04BA44,700
<br /> AVALON, T5 76423
<br /> 6a, 9b, U.S. DOT Description Qncluding Proper Shipping Nome, Hazard Class, ID Nurnw, f0, Containers 11. Tafel 12, Unit
<br /> NM and PflckingGroup (Ilany)} NQ, Type Quantity Wt.NOL 11 Waste codes
<br /> 1.
<br /> C�7 X Rq, [,.1N10#i , 1NAESTV FLAMMABLE l IQLliD:q , I\I . C) .; , 3, PGRf ) Ltfv1 85 t1 f)UO'f Uil'18 339
<br /> GASQLIM , Cit_ t?LIl'S 21 1H
<br /> W
<br /> 44
<br /> 3.
<br /> 4.
<br /> 14. Special Handling Instructions and Additional Information
<br /> ' INE tfc C) i!, EEZ0 # i28
<br /> t I14EROENGY GONTAC T: h4ARY
<br /> 15. GENERATORWOFFEROR'S CERTIFICATION; I hereby deciafe that the Contents Of INS Consignment are fully and accurately described above by the prOpelshipping name, aryl are classified, packaged,
<br /> Iriarked end fabeledtplacarded, and are ht all respgCts in proper condition for transport according to applioabie inleM tionaland national governmental regulations. If export shipment and I am the Primary'
<br /> Exporter, I cagy that the conlonts of this Consignment coftrm to the terms of the attached EPAgcknowledgmCQi of r pnsent.
<br /> 1 certifyihat the waste minimi�tlOn statement Idontified in 40 CFR 262.27(a) (if I am a largo quantity gonerator)jbr (b)pI sm a Small quemity generator) Is 1990
<br /> F68Asra s10%ror's PrintedtTped Name • �, Signature Montt ' p `/ rrd ft
<br /> r ,
<br /> F 16. intonational Shipments
<br /> ❑ Import to U.S, Export from. U,S, Port Of entry/exit: _ •_ * ,.
<br /> Tranapottar'signature•(for exports only); Date leaving U.S.: '
<br /> W 17. Trsmporterftnowledgment of Receipt of Materials
<br /> ~ Tran � PrinlBd/T Nama /� �1 IN NINE
<br /> a ! r �' y f gn r '� Month y Yebf
<br /> ' ! r' 1
<br /> TMV
<br /> ra ' rter2 'ntel y oma snafu Mo h Day Y r t
<br /> � t
<br /> 18. Discrepancy.
<br /> i
<br /> 18a. Discrepancy IndIC1lwn Spaca I
<br /> Quantity Yoe ❑ Resitlu(; ❑ Partial Rejection ❑ Full Rejection l
<br /> Manifest Reference Number,
<br /> 18b. Aifemate Facility (or Generator) V& EPA ID Number
<br /> Fepliilyk Phone;
<br /> w 18c. Signature orN(cmate Facility (or Generator)
<br /> tMonth Day Year
<br /> 19, HazardQus Waste Roport Management Method Codas (Le„ codas for hazardous waste treatment, disposal, and recycling systems)
<br /> 1. (( 2. 3 % .
<br /> l i�( v Iy 4, h .,
<br /> 20.,Dgs(gnated, Facility Owner or Operator: Gertificallon of teceipt of hazardous materials covered
<br /> Pdnte by the man)tCskexaept as noted In•Itom 18s
<br /> rr tped jVeme .
<br /> �gnatbre f •_ MOM Day Year
<br /> EPA Form 87110.22 (ROV, 3105) Previous editions tiro obsolete. �.
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