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AC- 03674, 2120 C / caO4"7"/ <br /> Please print or type.(Form des)gned for use on elite(12-pitch)typewrites) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.E Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST CAL00017843a , §M71k7449 0 03039801 G B F <br /> S.Generators Nam and Mating Address Generators Site Address(if different than mailing address) <br /> v ACNE SAW <br /> 9 1204 E MAIN ST <br /> 9, Generator's PhoM 105 <br /> STOCKTON,CA 95205 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL,INC. 27 7 <br /> 7.Transporter 2 Company Name AMERICAN <br /> EPA ID Number <br /> S.Dilisignated Facility Name and Site P4dress U.S.EPA ID Number <br /> GEM-RANCHO CORDOVA,LLC. CAD980884183 <br /> 118W WHITE ROCK RD. <br /> RANCHO CORDOVA,CA 95742 <br /> Faali s Phone:916-351-0980 <br /> 9a. 9b•U.S.DOT Description(mdhtoing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WtJVol. <br /> 1 NON-RCRA HAZARDOYLIS WASTE, SOLID, 1 OM 2455 P 223 <br /> ABSORBENTS 8 OIL <br /> all z <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PROFILE#757164.00,ABSORBENTS,ERGO 171 CONTACT;MARY <br /> 15. GENERATOR'S/OFFERORS 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 labelediplacanW,and are in all respects in proper condition for transport arx:ording to appficeble i irorral 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 EPAAcknorvtedg nt Consent <br /> certify that the w minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity�n or()(di aro sma quantity gene is hue. <br /> =00fferoes,&< yped Name Signa t Month Day Year <br /> d 23I . <br /> .r 16.International Shipments <br /> f. ❑Import to U.S. ❑Export from U.S. Pat of entryiexit <br /> 'z— Transporter signature(for exports only): Date leaving U.S.: <br /> W17.TransporterAcknowiedgment of Receipt of Materials <br /> Trans Name re Month Da Y r <br /> O <br /> O. <br /> aransporter d kWTyped Month Day <br /> 18.Discrepancy <br /> 189.Discrepancy Indication Space ❑ Quantity ❑Type ❑Reskhre ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> uQ Faclldtrs Phone: <br /> 10 i8c.Signature of Aitemate Facility(or—Genera" Month Oay Year <br /> 4 <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes Oe.,codes for hazardous waste traMment,disposal,and recycling systems) <br /> LU C 1 r�� 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of rwe^hazaftw matends covered by Bhe man fest except in Ilan 18a <br /> 1 Printed/Typed Name Signature ( Mon Day Year <br /> JAJ L, 0 (Q4 -1 <br /> EPA Form 8700-22(Rev 5) Previous editions are obsole .' <br /> 112250.1884 DESIGNATED FACILITYTO DESTINATION STATE OF REQUIRED) <br />