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Please print Or lype.(Fomt deli nod for use on ellle(7,Titch)typewriler' Form Approved.OMS No.2050-0038 <br /> i.Genamlor ID Number 2.Pa 1 of 3.Emer <br /> UNIFORM'HAZARDOUS 9e gencyResponse Phare 4.Manifest TroCkin Number G B F <br /> WASTE MANIFEST c,�L00021e2ea -� 2- q OC 4687 <br /> 5 Generator's Name and Mailing Address Generatoi s Site Address(if Moraman marling adamssi <br /> INDEPENDENT TRUCIONG <br /> 1145 W CHARTER WAY <br /> STOCKTON,CA 05206 <br /> Generalor's Phone2WA 1Q2 <br /> 6.Transporter)Company Name U.S.EPA ID Number <br /> SHOP HAZARDS SOLUTIONS,INC CAMOM6497 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 9,Designalad Facility Now and Site Adtlress GEWRANCW CORDOVA,LLC I U.S.EPA ID Number <br /> 111155 MITE KRD, C:4DOSO9WIM <br /> RANCHO cO M.A,CA 05742 <br /> Fadi ty's Phone: 918.351-OM <br /> go. Be.U.S.DOT Descriomn(inclurfng Proper Shipping Name,Hazard Class,lO Number, 10.CanUinen 11,Talal 12.Unit <br /> HM and Packing Group(dany)) i3.Waste Codes <br /> No. Type Ouanity WLNd. <br /> soca <br /> o pE6EL S00T FILTERS 8 gLYABSOFiBENT6 A-, DM 22r P 352• <br /> 2 <br /> 3. l <br /> 4. <br /> ® 14.Special Handling Instructions and Additional Information <br /> OWI-PRORLE OGR29072U0 <br /> APPROPRIATE PROTECTIVE CLOTHNG ERG 1117.1 <br /> FGENERATOWSIOFFEROR'STOWSIOFFEROR'S CERTIFICATION: I hereby declare that the commnls of this consignments NNy and a6curately described above by lh»�per shipping name,erd amclavdifd,packaged, <br /> nd labeled/plaarded,and are In all respects In proper carMNpn for transport according to applicable international end national gmemmental regula0ans.If export shipment and I am the Primary,I cer ily that the contents of this consignment tontine to the terms of The attached EPA Acknowledgment of Consent. <br /> hat the waste minimization statement idenifed in 40 CFR 262.27(e)(d l am a Urge quantlly generator)or(b l am as mall quantity generator)is true. <br /> Berofs Pdnted/fyped Name Signa Month Day Year <br /> /al ShipmentsImprito U.S. ❑Expel from U.S. Port ofenlryleail:Transponer signamm(for expodsonly): Dale Uaving U.S.: <br /> 17.Transport&AcknaMedgrom of Receiplof Materials <br /> '.mpeZ Prhkay1ypad Signature Month Day Year <br /> v Na a /a <br /> Qmanspoder rnmewlyped eme Signa re Month Day Year <br /> f <br /> } 10.Discrepancy <br /> 188,Discrepancy Indication Space <br /> ❑ Ouanilry ❑Type ❑Residue ❑Penial Rejection ❑Full ReJeclbn <br /> Manliest Reference Number: <br /> 106.Allemale Fealily(or <br /> J Generator) U.S.EPA ID Number <br /> U <br /> LL Faalily's Phone: <br /> �a�j 10c.$Ignalure ottdfemaU aNiy(or Generator) Month Day Year <br /> Z <br /> h19.Hazardous Weate Report Manegameal Method Codes(i.e.,Codes(of hazardous waste treatment,disposal,and recyding systems) <br /> 0 1. �� p 3. a <br /> } 1 20.Oeslg..Ied F1IIIY Ownerar Operator.CeNficegon of receipt of hazeNous materials covered by the mahifesl except as natetl in Ilam IBa <br /> Ptlnletllr ed Name Slgnalura� Month Day Year <br /> EPA Form 8700• - <br /> 22(Ray 3-05) Previous edlflons are <br /> obsolete. <br /> DESIGNATED FACT 0 DESTINATION STATE(IF REO <br />