Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) uxe Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000380778 +„' -A92 G B F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> NS AUTO}REPAIR <br /> 3403 E. MAIN <br /> Generator's Phone: <br /> STOCKT"ON,CA 95205 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL.INC. CAL 111JOA-2 7878 <br /> 7.Transpor�r 2 Company Name U.S.EPA ID Number <br /> r'1'4 CF1��L+C ��vll`�'11r; ,c111(al r(If16q ffl(�'1`'t d C{� � _� t�1� G'(.){�"II J <br /> 8.Designated Facility Name and Site Address ` U.S.EPA ID Number <br /> 1-18'1"CENTURY ENVIRONMEW AL M(MT OF NEVADA,LLC 'YVC)9808£�533(� <br /> 2095 NEWLANDS GR.EAST <br /> FERNLEY,NV 89408 <br /> Facility's Phone: 775-575-27M <br /> ga 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)) No. Type Quantity Wt.Nol. 3.Waste Codes <br /> C 1 RCS.,NA3077,HAZARAEYXJS WASTE. SOH N.O.S.,9, PGi11 nm <br /> 041EF (, ,roM,uM.al a 7 <br /> L 2 NON-RCRA HAZARDOUS WASTE,SOLID <br /> c� [DIRT,OIL.B ABSORBWI"S <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions anddditional Information <br /> :-'tiOFILE# 701( 1.00 , BRAKE SNAVINC-S,ERG#171 <br /> PROFILE#W 1051-r)D ,DIRT, 011,&ABSORBENTS, ERG#171 <br /> 15. GEN ERATOR'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 /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 W a small quantity generator)is true. <br /> Gena�rtorslOfferor'sPrintedrryped.Name Signature } (=—T''' Month Day Year <br /> J A( f <br /> 16.International Shipments <br /> [= ❑Import to U.S. ❑Export from U.S. Port of entrylexit L: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> tE Transporter 1 Printed/Typed Name . Signature Month Day Year <br /> N G ')A�<-t- <br /> Transporter 2 Printedrryped Name <br /> rTransporter2Printed/TypedName Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space -:. ❑ Quantity ❑Type1 <br /> ❑Residue. ❑Partial Rejection 1:1 Full Re ection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) of Nevada U.S.EPA ID Number <br /> thZ appropriate permits(s) <br /> <1 Facility's Phone: for, and Will accept <br /> Signature of Alternate or Generator Month Day Year <br /> LLj 18c.Si <br /> 9 Facility )t is generator is shipping. <br /> a <br /> Z <br /> A19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1. ` , � � � 2. 3. 4. <br /> H k I L( <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed(fypad Name t Signature j �^ Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> JUN J. 2 2015 DESIGNATED FACILITY TO GENERATOR <br />