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Please print or tyro. (Form desyned for use on eilte (12-pitchi ; a*easr.) <br />wF -0, 0-7651- 9 Y -� a�)Clc <br />Form A: Droved CYMB No. 2050.4039 <br />EPA Fom 9700-22 (Rall 3-05) Previous edibons are obsolete. <br />DESIGNATED FACILITY TO GENERATOR <br />AI IC 1 1 ?m <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />t. Gerurator l0 Number <br />""41- 6100 32'r 5� <br />2. Page of <br />1 3. Enw9ency Response Phone <br />14. ManMest Tmcking Number <br />J J K <br />1 <br />91q -842--o,.44012478962 <br />S. Gpedflo rs Name and Maft Address Generators Site Address (f different than mailing address) <br />j1-j�n�� � c 1� �h s•f �� -� <br />. <br />� i �� �- � h? <br />Czne�m ora Prore� 5_16 <br />6. Transporter 1 Company Name U.S. EPA 10 Number <br />SACRAMEi`i'i'O WASTE OIL CAL 911 514 (412 <br />7. T 2 Company Name } U.S. EPA ID Number <br />r..gnated Facility Name and Site mss U.S. EPA 10 Number <br />21st CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA, LLC <br />2"095 Nri:T ANDS lift. FAST :l Pu' LI3i , N7 98406 NVO 980 895 338 <br />Fealty's Phone: 775-525--2760 <br />ga- <br />9b U.S. DOT Description Cmdudmg Proper Shipping Name, Hazard Class,;D Number <br />10 Contalnem <br />11 Total <br />12. Unit <br />13 Waste Ccces <br />No. <br />Type <br />HM <br />and Packing Group (f any;) <br />Owfity <br />Wuvol <br />NON-RCRA HAZARDOUS WASTE SOLIDS <br />OIL SOLID <br />z <br />u.r <br />2, <br />c� <br />3 <br />4 <br />14 Spacial Handling Instructions and Additional Information <br />iANDL�RS lu' BE TRAINED AND USE' SPE <br />ERG # 128 -�7 � q <br />15. GENERATOR'S10FFEROR'S CERTIRCATION: I hereby declare that the contents of this consignment are k Ay and accurately described above by the proper sfiI h name, and aredasstW &raged. <br />,,nal governmental ulatiaa. If export shipment and I em the Primary <br />marked and labeledlptacarded, and am ,- a respects in proper condition for transport according to applicable international and na mg <br />Exporter I xray that the : tents of this consigmbnt contain to the term of the attached EPA Adat Medgment of Consent. <br />I certify that the waste mstim¢ation statement identified in 40 CFR 262.27(a) Cd I am a large quantity generator) or (b) (it. I am a small quantity generator) is true. <br />GeneraWslOfiemrs PrfntedlTyped Name Signature Moral Day Year <br />_.a <br />16. Intemabora Shipments - <br />❑ Import to U.S. ❑ Fsport Nom U.S. Pat of enlrylexil: <br />— <br />Transporter signature ?a exports--*)! Date leaving U.S.: <br />17 Transporter Admowiedgment of Receipt of Materials <br />TmnsporW 1 Prinled(Typed Name Signature Month Day Year <br />?2 .adrryped Nan'4 - Month Day Year <br />r/GLy- <br />f <br />18 D}sclancY r <br />18a Ofsaepancy Indication Space Y_! Quantity r Type L-! Residue - - -J QPadW Refection ❑ Full Rj@ction <br />CEM of Nevada <br />Manifest Reference Nuca1St <br />16b Alternate Fadtity,orGenerator) hast the a f738 <br />for, and will accepT the waste <br />ua. <br />FaciliY 5Phorhe thig nerator is shtpping- <br />Uj <br />16c So natum ofAilemate Facility (or Generator) <br />Writ h Day Year <br />a <br />z <br />19 Hazardous Waste Report Management Method Coda g.e., codes for hazardous waste treatment, disposal, and mcyding systems.I <br />a <br />i. _ �I — 2 <br />1 1- <br />3 <br />4 <br />20 Designated Fadi ty Owner or Operator Certification of receipt of hazardous materiars covered by the manifest except as noted In Item 1 as <br />Aedlrypac Name &gnature Year <br />EPA Fom 9700-22 (Rall 3-05) Previous edibons are obsolete. <br />DESIGNATED FACILITY TO GENERATOR <br />AI IC 1 1 ?m <br />