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Please print or type (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />1� ('. <br />2 Page 1 of <br />1 <br />3. Emergency Response Phone <br />4. Manfhst Trackinber <br />01247§933 <br />WASTE MANIFEST <br />.t. - �' <br />916-849-0144 <br />JJ K <br />5 Generators Name mid Mailing Address f n Generator's Site Address (if different than mailing address) <br />Generatofs Pyne: <br />6 Transporter 1 Company Name <br />US EPA 1D Number <br />SACWIENTO WASTE OIL <br />CAL 913 _534 912) <br />7 Transporter 2 Company Name <br />U.S. EPA ID Number <br />8 Designated Faality Name and Site Address <br />U S EPA'D Number <br />21st CENTURY ENVIRONMENTkL MANAGDIENT OF NEVADA, LLC <br />2095 NEWLANDS DR. EAST FERNLEY, NV 98408 <br />080 Sus 330 <br />775-525-2760 <br />Faality/s Phone: <br />ga <br />9b U S DOT Description (mdud rig Proper Shipping Name, Hazard Class. ID Number. <br />1 C. Containers <br />11. Total <br />12. Un8 <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Padang Group (if ony)) <br />Quantity <br />"fico. <br />1. <br />352o <br />NON -,MCRA HAZARDOUS WATE SOLIDS <br />? <br />( OIL SOLIDS } <br />z <br />2 <br />w <br />3 <br />4 <br />14, Specd HarAft Instructions and AddNonal Information r <br />HANDLERS <br />TO BE TRAINED AND USE FPE <br />_ <br />ERG f 128 PROFTLE fi <br />i <br />15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippkhg name arhd are classified, packaged, <br />marked and fabeledfplacanded, and are In aft respects kr proper condition for transport according to applicable international and national governmental reputations If export shipment and I am the Primary <br />Exporter. I cartity that the contents of this consignment conform to the terms of the attached EPAAcimowledgment of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 2BZ27(a) (d I am a large quantity generator) or (b) (d I am a small quantity generator) is true. <br />Generatds0flaror's PrintedlTyped flame Signature <br />Month Day Year <br />.1 <br />F <br />16 International Shipments <br />❑ mpon to U S ❑Export from U S Pat of entrylexit <br />? <br />Transporter signature (for exports orgy) Date leavag U S <br />17 TrancporterAdinowledgment of Receipt of Materials <br />Transporter 1I Pri yped Name 1 Signature <br />Month Day Year <br />CL <br />:`{ 1 `f'l T I !�i`. `VIS r ( c�L T <br />,r <br />QTransporter <br />2 Printeddtyped Name Signature <br />Month Day Year <br />16 Discrepancy <br />1 ea. Discrepancy Indication Space Quarhtity ❑ Type ❑ Residue <br />❑ Partial R*don <br />❑ Feril Reed. <br />Manifest Reference Number. <br />18b Alternate Facility for Generator) <br />U.S. EPA ID Number <br />.a <br />U <br />lax.. <br />Facilityrs Phone' <br />w <br />18c Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />Uj19. <br />Hazardous Waste Report Management Method Codes 0.e., codes for hazardous waste treatment, disposal and recycling systems) <br />0 <br />1 <br />2 <br />3 <br />4. <br />20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Ba <br />Primedrlyped Name agnature <br />Month Day Year <br />EPA Form 8700-22 (Rev 3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />