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Please print or type (Form designed for use on elite(12-pitch)typewriter) Ld2 MB No,2050-0039 <br /> UNIFO HAZARDOUS 1 Generator ID Number 1 Page t N 3 Ernergenry Response Phone 4.Manlfesl Tracking Number <br /> STE MANIFEST CAC002836782 1-71 209-937-8374 002829321 G B F <br /> 5.Generator's Name and Mailing Address Generator's Silt,Address(if different than ma9mg address) <br /> CITY OF STOCKTON <br /> 800 EAST MAIN ST <br /> STOCKTON,CA 95202 <br /> Generator's Phone 299-937-8374 <br /> 6 Transporter 1 Company Name U.S EPA ID NumberAMERICAN VALLEY WASTE OIL,INC. CAL000827878 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number21 st Century Environmental Management of California LP CAR000210617 <br /> 8 Designated Facility Name and See Address 21ST CENTURY ENVIRONMENTAL MGMT OF NEVADA,LLC U.S.EPA ID Number <br /> 2095 NEWLANDS DR.EAST NVD980895338 <br /> FERNLEY,NV 89408 <br /> Facility's Phone: 775-575-2760 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners 11 Total 12 Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Codes <br /> 1NON-RCRA HAZARDOUS WASTE,SOLID ABSORBENTSOIL 1 BA P 223 <br /> � , I <br /> o DIESEL <br /> a4 ` <br /> w <br /> z 2 <br /> w <br /> t, <br /> 3 <br /> i <br /> A <br /> 14 Special Handling bust actions and Additional Information <br /> PROFILE#734836-00,ABSORBENTS,OIL/DIESEL,ERG#171 <br /> CONTACT;SHARLA HARDY <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Cully and accurately described above by the proper shipping name,and are ckassiW,packaged, <br /> marked and lahalerflplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations It export shipment and I am the Primary <br /> Exporter,I certify that the contents of Nis consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization otalement identified in 40 CFR 262.27(a)(e I am a large quantity generator)or(b)(if I am a small quantity generator)is froa. <br /> Gene r I r's, a is Printed/Typed f Signal Month Day Year <br /> J 1b.fritematimal 1111imorils <br /> ZLJ Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature((or exports only): eav' U S. <br /> w 17.TranspoderAcknowledgment of Receipt of Materials <br /> Li Transpo 1 Printed ,ped Nanta <br /> rgrknture ay ear <br /> 21 <br /> Q 1ITtenspohdr.P riled/Typed N <br /> S' Month Day Year <br /> I- _r1Al i� �P �!/',L" 4 rl�� / <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space Quan6t F� <br /> Y ❑Type Partial Rejection F__1 Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C18c.Signalure of Alternate Facility(or Generator) Month Day Year <br /> H <br /> Q <br /> z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2 3. q. <br /> 20.Designated Farilily Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except cxed in Ilam 18a <br /> Prmled/Typed Narne . � Signature c, Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous eddions are obsolete. <br /> nFr 1 7-TMTBESIGNATED FACILITY TO DESTINATION UATE(IF REQUIRED) <br />