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Please .rint or ",(Fonn des•-ned for use on elite (12•eitch) mevniter.) Form Anomve-1 OMR Nn 20SDM144 <br />t: Foran tsm-a ("v 8-05) Previous editions are obsolete. jDESIGNATED, A ILITYTO GENERATOR <br />MOD n A 7nif <br />UNIFORM HAZARDOUS <br />1. Generator ID Nianber q �+ <br />(4 1-6 � 3Z SG 7 <br />2.Page 1 d <br />3. Emeryerxy Response Phone <br />916-849-0144 <br />4. Manffnt Tra Nwrd,er <br />012478933 JJ K <br />WASTE MANIFEST <br />1 <br />it.' <br />5 Generator's Name and Mailing Addresn Generators Site Address 't different than malting address) <br />Generator's Phone: <br />6. Transporter 1 Company Name U S EPA tD Number <br />SACRAMENTO WASTE OIL CAL 913 534 912 <br />7 2 �y1Q ii II U S. EPA D <br />i <br />8 Designated Fad* Name and Still Address U.S EPA IDN ober <br />�lst: CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA, LLC <br />2095 NF 414 ANDS DR, FAST -wF-R_NLFY, NV 98408 WD 980 895 338 <br />Facili-vs Phone: 775-525-2760 <br />9a. <br />9t• U.S. DOT Description (including Proper Shipping Name Hazard Gass, ',D Ntmhber. <br />1.: Contain srs <br />11 Total 12 Unit 13 Waste Codes <br />No <br />Type <br />HM <br />and Pacdnig Group (if any)) <br />Quantity WtNo l <br />o <br />1. <br />NON-RCRA HAZARDOUS WATE SOLIDS <br />35l <br />( OIL SOLIDS } <br />W <br />2. <br />CD <br />OD <br />3. <br />M S1all <br />4 <br />MMI <br />QiJIP �� <br />14. Spe ice! Handling instructions and Additional Infannation <br />HAtiTiLEi,8 TO bC' TRAILED AND rte; PPF �q j1 (pUd <br />ERG # 128 PROFILE # 6a -7L _ a� <br />15. GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the moments of this consignment are futy and ax ralely described abode by the proper shlppmg name, and are dassified, packaged, <br />marked and bbeledlplacarded, and are in as respects in proper condition for transport according to applicable ntamattrial and national governmental regulators. If export shipment and , am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terns of the attached EPAAduhowledgment of Consent. <br />I certify that the waste minimizabon statement Identified in 40 CFR 262 27(a) (d I am a large quantity generator) ar ;b; i' I am a small quantity generator) is true. <br />G`erwatorvpI erces Printed/Typed Name Signature Month Day Year <br />16. 111 Shipments <br />❑Import toU.S. Export from U.S. Porto[ entry - <br />x <br />Transporter signature !for exports only;: Date Ieaving U.S.: <br />17 Transporter AdmaMedgment of Receipt of Materials <br />Tr��ann+sporter, , PnItiolfyped Name Signature Mwth Day Year <br />,y} <br />{ Morith Day Year <br />'� I ir <br />18 D'uaepancy <br />__ <br />18a. DD*repancy 'ndieatlon Space Quantity Type ^Residue <br />M%vPo .x. El F.5 Rrr.ejec adn <br />21st Cl o, <br />Manifest NWA-heiMpropriatepermits(l) <br />18b. Alternate FaeLty (or Generator) <br />f or, and will ���@�t'"I'i�e waste <br />this generator is shipping. <br />Facity/aPtwrhn <br />W <br />16c Signature of Alternate Facility (of Generator <br />Vanth Day Year <br />Q <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codec (Le- codes for hazardous waste treatment, disposal, and recycling systems; <br />ni <br />}/'� <br />2. <br />3. <br />4. <br />2D Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest e - need In Item 18a <br />Printed/Typed Name Igna ' Month Day Year <br />f <br />t: Foran tsm-a ("v 8-05) Previous editions are obsolete. jDESIGNATED, A ILITYTO GENERATOR <br />MOD n A 7nif <br />