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<rm` fro 0 q q <br /> 'Ie�''type Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2Pagel of 3. EmergenyResponse Phone 4. Manliest Tracking Number <br /> WASTE MANIFEST CAL000286266 20954&5012 0 0 6 239755 G B F <br /> 5, Generators Name and MadingAddmss Gsneralorsbee Mines (a different Than malithg address) <br /> H&M MARKET BWi <br /> 531 MCHENRYAVE 2501 E. JACKSON <br /> MODESTO, CA 95354 <br /> Genemtoesphpna0S-50-5612-105 ESCALON, CA 9532Q <br /> 6. Tmmpo ter 1 Company Name F U.S. EPAID Number <br /> AMERICAN VALLEY WASTE OIL, INC , CAR000272302 <br /> 7. Tmmpodar2 Company Name U.S. EPAID Number <br /> STERICYCLE SPECIALTY WASTES )LUTIONS, INC MNS000110924 <br /> 8, Designated Facility Name and Site Address U.S. EPAID Number <br /> 21St' CENTURY ENVIRONME MAL MGMT OF NEVADA,LLC NVD980895338 <br /> 2095 NEWLANDS DR. EAST <br /> FERNLEY, NV $9408 <br /> Facgiys Phone775-575-2760 <br /> ga, <br /> Do. US. DOT DespiidwOndw5ng Pmperfalpping Name, Hazard Class, ID Nui doer, 18. Conlalnam 11. Tolm 12, Unit <br /> HM aid Paddre Group (lfany)) ji No. Type Quantity WtNol. 13.Wasle Codas <br /> An X 1 RO, NA3077, HAZARDOUS WASTE SOLID, N.O,S... GP PGIII, GASOLINE 1 DM 190 P D018 352 <br /> & DIESEL PUMP FILTERS & HOSES, BENZENE <br /> 2. <br /> [J <br /> 3. <br /> 4. <br /> 14. Special Handling lmiNCUon9 O2Additional Information <br /> PROFILE# 7907298£ GAS FILTERS, HOSES, ABSORB ENT ERG# 171 <br /> EMERGENCY CONTACT: MONICA <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION; I hereby duelzre that the conlentafUs consynmentsre Miry out Ancuretdydesmbed above bythe pmparshipping name, and are dass'fied, pa&aged, <br /> marked and labelecilpaearded, and are In all respects in proper candiBon for hanWe toweaurst to appffcabla Internationaland natiamigwemmenlel mgulaiam. Ilexpat shipmenterd l amthe Primary <br /> Exporter, I CeAy (hat the mntenls ofthlscaugnmm(conform to the isms ofthe at aded EPAAcknovvedgmento(Coment <br /> I certify that mewasta mhdmration sidernert identsum In 40 CFR 262.27(a) 0 [ am a large quantity gonareror)or (b) (III oma smaliquangtygeneralor) Is We. ' <br /> Generatoed0fl cora PrinleQRyped Name a SlpmMm Monty Day V r <br /> �® <br /> IS, latemi'lional Silipmenut ❑ Impodto U.S. ❑ Expodfmm U.S. Palofenkyeat <br /> TrMspodw slgnaNre (forexpats mty); Date leaving U.S.: <br /> K 17. TrenspodefAd=WedgmaMa(RecdplofMate4ls <br /> Transporter 1 P ' d Na Signa INV Month Da y <br /> O <br /> Transport 2 n gnatu <br /> Month y <br /> 1 <br /> 10. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quamity ElType El Residue ❑ Postal Rejection El Full R{echon <br /> 181a.Altem me Facility(or Gemmtw) Mantes Refemnce Number. <br /> U.S. EPAID Number <br /> U <br /> LL Fadliys Phone: <br /> �j 180. SignaMre " ntoumw Famgtor Genemtor) Morch Day Year <br /> Q <br /> W 19. HaccaNP /411 <br /> ouus Waaste Repod Management Method Codes (i.e., codes for hazardous wast tmabmnh disposal, and recycling systems) <br /> C2 1 / ,'} / /eR1 2 3. 4, <br /> 20, Deslgnaled Facility WmerprOcemlor. Certification of remipl of hazardous maledals veredbythe mangast cepl as noted In Ilam 18z <br /> Prime a Gignaw ^win .•DDaay Year <br /> I ✓ <br /> EPA Form 8700-22 (Rev. iz-t revlous ediuons are Obsolete. , ,. , DESIGNATED FACILITY TO EPA's D•MANIFEST SY <br />