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1 <br /> � X07-3 <br /> Please print or type.(Form designed for use on elite(12•ptfch)typewriter,) Form Approved.OMB No.2050-0439 <br /> J75 <br /> M HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phone 4.Marftast Tracking Number C <br /> E MANIFEST n G B f <br /> CALOD0158778 i 201-1370-46II9 � <br /> tor's Nano and MaRingAddress GaneralVs SiteAddress(if dfferent than marling address) <br /> SYSTSA TRANSPORT.(TUVT) <br /> 707 E. ROTH RD. <br /> FRENCH CAMP,CA 55321 <br /> s Phone'rter 1 Company Flame U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL, INC. CAL0004167i4 <br /> ter 2 Company Nama U.S.EPA lD Number <br /> 1A0 T ,VA.PVv -�i Cid �11�C 10b Ied FaGGIy Name and Sit Address U.S.EPA ID Number <br /> GEW)-RANCHO CORDOVA,LLC. CAD98M84181 <br /> 11665 WHITE ROCK RD. <br /> RANCHO CORDOVA,CA 1957,32 <br /> Facility's Phone:918'351-09$0 <br /> ga 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Conlaine s 11.TOral 12.Unit 13•Waste Codes <br /> HM dr Pachjng Group(if any)) No. Type Quantity wtNo!. <br /> 1 NO RCRA HAZARDOUS WASTE SOLID � � DM M- P 223 352 <br /> O ABSORBENTS,DEBRIS CM OIL,DIESEL <br /> 9 <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special HarndEng Instruct ons and Additional Informa'�on <br /> PROFILE 0 898675-01 ASSOft6ENTS, SEE ERG 0171 EMERGENCY CONTACT:SMA <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the convents of this consignment are fully and accurately desorM above by the proper shipping name,and are classmed,packaged, <br /> marked and labeladlplacarded,and am in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and r am the Primary <br /> Exporter,I cortify that the contents of this consignment conform to the terms of the attached EPAAcknowledg me nt of Consent. <br /> I certify that tho waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity genorator oT(b)(if I am a small amoral Is true. <br /> G M s10 aro sPdn ypedNz� Sig ture / Month Day Year <br /> .� 1 .ntemational Shipments �• <br /> [~. 11Import to U.S. Export from US. Port of entryley is <br /> z Transporter signature(forexports only): Date leaving U.S.: <br /> LU 17,TmnsportorAda;wAedgmeniolReco,ptofMaurats <br /> a Transpo ter a aluren Day Year <br /> a ! / <br /> QTran rto a _ Oay r <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Reject on <br /> ManNesl Reference Number. <br /> 18b.Alternate Fad7ity(or Generator) U.S.EPA 1D Number <br /> V <br /> LL Facility's Plrone: <br /> w 180.Signature ol`Memate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Meftd Codes Q.e.,codes for hazardous waste treatment,disposal,and recycI'M9 systems) <br /> 01. I 1 2 3. 4. <br /> 20.Dasignated F alily Cwner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item <br /> Pdnted/T me C\��!—/ Signature Month Day Year <br /> C r(, r(t Cit <br /> EPA Form 870U-22(Rev.3-0 ) Previous editionsar&absolete. <br /> DESiQNA FACIl.ffYTO GENERATOR <br />