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Please print or type. (Form designed for use on elite (12-pitch) iypevniter.J - �I � Form Approved. OMB No. 20SM39 <br /> 2 Page 1 of 3. Emergency Response Phoria 4. Manifest Tracking Number <br /> UNiFC{Rld EINZARp01lS - 1, GenaratalDNumber 003371084 G B F <br /> WASTE MANIFEST CACQI)2895376. - A426 <br /> 5: Generators Name and Maatng Address Generator's SheAddress (d different than mailing addrosa) <br /> SPAULDING TRUST <br /> 540 NORTH EL D.ORADO .STREET <br /> STOCKTON; CA 96203 <br /> Generators Phone:707-812-1426 <br /> 6. Transporter 1 Company Name US. EPA ID Number <br /> AMi R16AN VALLEY WASTE OIL, INC. CAL000416?14 <br /> 7. Transporter 2 Company Name U.S. EPA1D Number <br /> STERICYCLE SPECtAI_TY WASTE SOLUTIONS, INC. MNS000110924 <br /> 8. Designated FaaTrty Name and Sito Address U.S. EPA ID Number <br /> 21ST CENTURY ENVIRONMENTAL MGMT OF NEVADA, LLC WDS80895338 <br /> 2095 NEIWLANDS DR . I=AST <br /> FERNLEY, NV 89408 <br /> > FacifrtyrsPhone: 77&575-2760 <br /> ga. 9b, U.S. D0T1DesaipWn potteM ProperSE lAft Name, l farard Class. ID Number, ,0. Containers 11 . T0ta1 12. Unit 13. Waste Codes <br /> H_ M and Packing Group (darn}) No. <br /> Type Quantity WtNoI. <br /> 1• NON-RCR HAZARDOUS WAS'1E LIQUID, WATER & OIL 1 DM 30 G 241 <br /> 0 <br /> a <br /> z ' 2 <br /> w <br /> 3. <br /> 4, <br /> _ — u <br /> ,4 4 t S 3 -= M = <br /> jmom � <br /> • ,4. SpeclatHand6ngfnsWctior>SandAddrtiawllnformation - <br /> PROFILE# 830454-00 WATER & OIL ERG# 171 i` � � € ' ` � �1 � ` '' � <br /> EMERGENCY CONTACT: WILLIAM NAMNATH <br /> 15m GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contents of this mnskjament are fully and aoauatefy described above by the proper sfupaug name, and are classified, padaged, <br /> markedand labeledfpfacarded, and are in all respects in proper ocomon for transport aoeordmg to appficaVe intemationaland national governmental regulations. if export shipment and f am tha Primary <br /> Exporter, I certify Dot the contents of thus consfgnmenf conform to the terms of the attadied EPAAc wMedgment of Consent, <br /> cedify that the waste m'rmn¢ation statementidenti_W In 40 CFR 262.27(a) (d t am a large quan* generator) or (b) (di am a we] quantity generator) is true. <br /> Genenatoesf0ft s Printsdffyped Name Signature Mon r <br /> 9yj <br /> J <br /> J 16, International Shipments <br /> i— ❑ Import to US, El wort from U.S. PottDate olea n U.S.: <br /> z Transporierslgnature (lorexponsady): <br /> LU 17.TransporterAdawwiedgmenlofReceiptofMatedals <br /> a TransporterlPAnt Name Day Year <br /> a <br /> Transporter 2PrfntewrypoHorne Zl4aature Month Day Year <br /> � <br /> 16.0'�ctepancy <br /> 18a. 0isaeparscy IridicationSpace ❑ Quantity © Type ❑ Residue ElParria1 R*oon ❑ Full Rejection <br /> Manifest Reference Number. <br /> ,fib. AltemateFaaTrty (orGenerator) U.S. EPAID Number <br /> ti <br /> W FaciTiVs Phone: <br /> w l6aSlgnaWreotAttemateFacdily (o( Generator) NNW <br /> Month Day Year <br /> Q <br /> z <br /> W. Ha=deus Waste_ pod Management Method Codes (te., codes foi hazardous waste treatment, disposal, and recycling systems) <br /> p 1, f ) / -� 2. 3. 4. <br /> 20. Designated Fac, ty Owner or OperafoC Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a , <br /> PnntoOyped Name Signature Month Day . Year <br /> rn <br /> EPA Form 870022 (Revs 3.05) Previous editions are obsolete, <br /> "(IF I�EQUIREp) <br /> FEB #2 4 2017 DESIGNATED FACILITYTO DESTINATION STATE <br />