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'lease print or tyfpe.(Form designed for us�o� elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UPIFCRM HAZARDOUS 1 Generator 10 Number 2.Page 1 of 3-Emergency Response Phone 14.MaWfest Tracking Number <br /> yY $Jlz MANIFEST CALF 2 361-7T21 003040334 G B F <br /> 5. enera:or's Name and Mailing Address Generators Site Address(it different than mailing address) <br /> ARWAftil{Lft FORM 8 CAR kER APP <br /> 7670 S.LONGE ST <br /> STOCKTON.CA 95206 <br /> Generators Phone 2 M361-7'7 2'1 <br /> fi.Transponer 1 Company Name U-S.EPA ID NumSer <br /> AMERICAN VALLEY WASTE OIL, INC. CALQ00827878 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 219t[V*- Fi'ACtiElfliEl&W NWmgamerd dfCakfa is LP CI�OZIM7 <br /> 6.Designated Fa&y Name and SiteAddres%— U.S.EPA ID Number <br /> 21ST C RY EWROIii MENTAL MGMT OF NE1 PMkLLC NvD9soag5 6 . <br /> 2085 NEWLANDS DR.EAST <br /> FERNLEY,NV 88400 <br /> Facility's Phone: 775-575-2700 <br /> oa. 9b.U.S.DOT Descrip'ion(including Proper Shipping Name,Hazard Class.ID Number, 10.Con;a hers 11.Total 12.Unit <br /> HM and Packing Group(If any)) 13.Waste Codes <br /> No. Type Quantity Wr.Nal. <br /> 1. <br /> NAI 983 COMBUSTIBLE LIQUIDS,N.O.S.,COMBUSTIBLE LIQUID, ZD DM aff a 147 <br /> PGf 11 110 <br /> W POLY 0XY-1,2-ETHANEDfYL0 <br /> W 2' LIN3412WASTE FORMIC ACID,8, PG11 Dm <br /> 2a O Daae 141 <br /> L9 <br /> - ti <br /> s. ID. Awl <br /> 4. <br /> C <br /> 14.Special Ha,dling Instructions andAdd]Jonal Information <br /> W PROFILE07537'27-a0,TURBO FRES#,ERGS 128 <br /> W PROFILW53732-M,INJECTION SOUR.ERG#153 <br /> ���� CONTACT;TOM DIKOS <br /> 15.•:GENERATOWSIOFFEROWS CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by he proper shipping name,and are classified,package6A" <br /> marked and labeledlplacarded,and are in all respects in proper cordi on for transport aeearding;o applicable ir:emational and national governmental regu'ations.1;export shipment and I a.m the Primary <br /> Exporter,I certify that.the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify tha+the waste minimization stalement identified in 40 CFR 262.27;a)(if I am a large quantity generator)or(b)(if I am a small quantiy generator}is ir'ue. <br /> GenerataesJDfferors PrintedfTyped Name '"' :. yet: S gna r _}.. Month-' ay*,�•Year.N <br /> r .�.ri=kms �• � � =- =�r� �:���: ' r <br /> 15.lime-naJonal Shipments <br /> ❑Inn Don to U-S. ❑Expo from U.S. Port of entryfexit: <br /> Transporter signature(for exports only): Date Ieavir.g U.S.; . <br /> Y 17.TransporterAcknowledgment of Receipt of Materials <br /> y <br /> y Transponer antedflyped 5igna:ure Month Day Year <br /> n <br /> TrarsVj 2 PrintedlTyped Si azure Mo ay ear <br /> ,a.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type Residue Partial Re ecton <br /> ❑ ❑ j ❑Full Rejection <br /> Manifest Reference Number: <br /> 186.Altemate FaciJ;ty(or Generator) U.S.EPA ID Number <br /> Fao1il11s Phone: <br /> L 155.5ignaaere ofAJtema"e Fadli y(or Genera OF) _ Moa`•h Day Year <br /> r - <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recyding systems) <br /> 20.Designated Facility Owner or Operator:Certi.ca• n of receipt of hazardous materials covered by the manifest except as ncLed in Item 1 Sa <br /> Pan yped Name Signaaire Mo pay Y-F <br />'A Farm 87 0-22(Rev. 5) Previous editions are obsolete. <br /> A O O ,„?� ^-SIGNATED FACIL.FTYTO GENERATOR STATE (IF REQUIRED) <br />