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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 <br /> 1.Generator ID Number 2.Page 1 of ,3.Emergency Response Phone 4.Mal TrackZ",-u,4" 5 <br /> ng Nu <br /> > (� <br /> WASTE MANIFEST CAL43003H1886 L¢ f p 7 G B F <br /> S.Generetoes Name and Maifng Address GeneratoYs Site Address(f different than mailing address) <br /> SANGLdINETTI INVESIMENlS LLC <br /> IBt-338COPPEROPOLISRD 4469 S.ESCALONE BEL LOTA RD <br /> LIDEN,CA 95236 FARMINGTON. CA 95230 <br /> Geren Transtoes porter <br /> Company Name 29 <br /> 6.TranspoMr 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 /> ST LRIC YCLE SPECIAL I WASTE SOLUTIONS,INC. MNSD00110924 <br /> e.Designated Facility Name and Site Address _ - U.S.EPA ID Number <br /> - <br /> CHEMICAL RECLAMATION SVCS TXD048844700 <br /> 4U5 POWELL STREET <br /> -�AVALON,TX 78823 <br /> Facility's Phoned72-(327-3224 <br /> 9891h.U.S.DOT Description[Including Proper Shipping Name,Haraal Cleat,ID Number, 10.Containers 11.Total 12.Unit 13 Waste Codas <br /> HM and Padang GrouP(if any)) No. Type Quantity N ivol. <br /> X 1' RQ.LR4126H WASTE PETROLEUM DISTILLATES.N.O.S., 3,4PG41. I DM � G 0001 0018 331 <br /> GASOLINE,DIESEL -�0 OUTS 211H <br /> I <br /> z 2. <br /> W � I <br /> e7 <br /> 3. b <br /> 4. <br /> 14.Special Handling Insbucl m Md(diRonal IntOrMSOn <br /> PROFILE#758(382-01 GASOLINE&WATER ERG1 128 <br /> EMERGENCY CONTACTRON <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,a id are classified,packaged, <br /> marked and IabeleNplaarded,and are in all respects in proper condition for transport according to applicable kaemationaland national governmental regulations.9 export shipment and I am the Primary <br /> Exporter,I cerdly that the contents of this consignment conform ld the terms of the attached EPAAcknoMedgment of Consent. <br /> I ceNfy that the waste minimizaborn statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(RI am a small quantity,generator)k the. <br /> Gerrerut'st0lfemis PnntedfTyped Name SgnaWre . Month Day Year <br /> 5 1 L2 <br /> 16.Intemational Shipments ` <br /> F I ❑Import to OS. ❑Egwn from U.S. Dadof ving U.& <br /> Transporter sgnawre(farexportS only): Date leavingU.S.: <br /> W 17.Tmmpor AdwMedgmenlof Receipt of Malenals ' <br /> r. Transporter 1 .7,yped Name Signature Manch Day Year <br /> II G <br /> 2 Sgnature Ll Man �D?Y Year <br /> Trarreponi 'nlednyped LL1J <br /> K <br /> 18.Discrepancy <br /> 18a.Discrepancy InUisafion Space ❑ Ouan6ty ❑Type ❑Residue {❑Partial Rejeution , ❑FUN Rejection <br /> Manifest Reference Number <br /> 18b.Afemate Facility(or Generator) U.S.EPA ID Number <br /> Zi <br /> U <br /> LL Facility's Phone: Month Day Year <br /> w 18c Signature ofFRemale Faality(or Generator) <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treaMenL disposal,and rerydirg systems) <br /> G 1 Z 3. 4. <br /> 20.Designated Facility Owner or gKinalor.CeoaAon of recipil offlatendki materials covered by the man'dest a as r in Rem 18a - <br /> 1 PnnledRyped Name `> Signature,l kp n raY ear <br /> / \ C <br /> _—------________ - � <br />