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Form Approved, OMB No. 2050-0039 <br /> Ile <br /> 1. Gaheamr lO Number 2. Page1V( 3. Emargancy Resporea Phone 4, Ma Hostliaaldn Numbe^r� <br /> rrr B STtl3 CAL0002862W 1 209-54&5612 O O u 2 9 i :5 4 GBF <br /> . . . Oat ar§ Name and MapinsAdfive; MARKET BVJN88 Generators %Address (11dMerentCan mapNg address) <br /> 531 MCHENRYAVE 2601 E. JACKSON <br /> MODESTO, CA 95354 ESCALON, CA 95320 <br /> ilemimforsPhon?09-549-5612-105 <br /> 6 Ironstones 1 Company Name U.S. EPA ID NumberAMERICAN VALLEY WASTE OIL, INC. CAR000272302 <br /> 7.TmnsWer2 Company Name I U.S. EPA ID Number <br /> r . STERICYCLE SPECIALTY WAST SOLUTIONS, INC MNS000110924 <br /> 8, Designaled FadlityNameand8de'AddressU.S. EPA ID Number <br /> GEM-RANCHO CORDO , LLC. <br /> N <br /> 11855 WHITE ROCK RD, <br /> CAD8B0884183 <br /> RANCHO CORDOVA, CA 96742 <br /> Fad sPhona9'16-351-0980 ' <br /> Re. Ih.U.S.DOT Deeaiplbn (Nduling Proper Shipping Name, Hazard Class, l Number, 10. Conrolnem 11. 14101 12, Unit 13. Waste Corks <br /> NM and Paddig Group If any)) tNo. Type Quantity WIN4I1 <br /> X 1. RQ, UN1266, WASTE PETROLEUM DISTILLATES, N.O.S., 31 PGII, 1 DM 55 G DO01 0018 331 <br /> GASOLINE, DIESEL <br /> T� 2. <br /> f7 <br /> 3. <br /> 4. <br /> 14,Spa dal HandNg belmoUona met Additional Information <br /> PROFILE#790731-02 WATER & GAS ERG#P128 <br /> EMERGENCY CONTACT: MONICA <br /> 15, GENERATORS/OFFEROR'9CERTIFICATION: liberethydeclamotmathaw onto of Ws nonalignment amfullyaM actoramlydescribed above by flue proper6hlppggneme, ardaredaseffi , peaheged, <br /> marked and lebelolooearded.and sie [gal map" In propercoP14on tort' portwondmg bapgleablofmemavonaland natlonalgovemmentel reguletiana. Ifexpo4ahlDmadeMlam tlwPrimary <br /> Expod§r, l'ceigfyMatlha wnNntsp(JhlsNruslgnmenlconrortnbtlletenne of eadaded EPAAdnaMadymen(ofCanseni. <br /> I week that the steam m nlemodom'.addimanlidentl ecl In 40 CPR 20227(t),(I l am alarge quarthygonsralor) or IifI em a small quanMyWarabr) is Wa <br /> Oeremtoeslgfemra PenledfTyped Noevmwm Month Day Year. <br /> F r0 <br /> i6. lnlemegaual ShlpbenLa : ' <br /> ❑ Impontaus, &pod from U.S. Pod ofedryfeut <br /> Transporter sommus (for oxpo4od�):. Dale leming LLS.: <br /> 11.TmmpadarAdm4wfedgmedof RecBlWof ds <br /> TrereDwlaz t. $. as Month DaY Y <br /> C <br /> 6. <br /> Transportd em0 Shmew W USY <br /> y t <br /> 18. DNaepatwy . . . <br /> Ila, Dlseepamy Indication Specs ❑ Quantity DType ❑Raoldie ❑ Partial Rejection FOR Relec6on <br /> M eslRaferanmNumber. <br /> 164;711emete Fadldy or Geneator) - U,S. EPAIDNumber <br /> F§,c8M.Phgue: <br /> .6NnaiwpofA'lamate aP (4rGammor) 163 . ear ' <br /> ,Me RBjroitMandgeup9nYMatiiod Codas (la, ogd0sror weetotreagnaM,dgpaei eMreSyalip:,. , mel <br /> 2. 3. 4 <br /> JAI <br /> r <br /> ,salad Fa4ktyOwnprgOperemn Cerllkatlonalrecalplofharaudourema ' caveradby gwmenlfesfexceptas nded Nllem l8a ypad Name Sgnd m Month141 <br /> AAAr <br /> ; 6o-22 (Rev. 12- 7) F%*us edl ons ate obsolete. DESIG D FACILtiY TO ERA'c B MANIFE <br /> eSr } <br />