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Please print or type.(Form designed for use on elite(12-pllch)typewriter.) <br /> 7.Gonemar ID Mrmher Form A Proved,(We No.2050.0039 <br /> ® UNIFORM If 2.Page 10l 3 Emergency Response Phoma 4.f/�ynipsp�q rae1�cln u �j p <br /> WASTE MANIFEST CAL000216286 1 200-712.883D Mal 1 4 L„ G f7 F <br /> 5.Garmralors Name and Malting Address Generators 811e Adtlreas OfaUlerenl aan mailnp adtlmss) <br /> INDEPENDENT TRUC14NG <br /> 1145 W CHARTER WAY <br /> STOCKTON,CA 05208 <br /> Generators Phone?00-088-5182-105 <br /> G. As <br /> 1 Company Nemc U 3.EPA ID Number <br /> SHOP HAZARDS SOLUTIONS,INC CA0000848407 <br /> 7.TranspoW 2 Company Name <br /> U.S.EPA 10 Number <br /> B.Oasigraled FaclgfyNama and SifeAUtlress GEM•RANCHO CORDOVA,LLC, U.S.EPAIUNumber <br /> 11655 V.MTE ROCK 90. C�4DOBOS84103. <br /> RANCHO CORDOVA,CA 05742 <br /> Facllt,s Phone 016-351-00M <br /> 9a, 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11. Unit <br /> Total 12. <br /> HM and Pscvng Gmup(ifany)I No. Type Ouen8ly W.Unit 13.Waste Codes <br /> o DIESEL SOOT RLTERS 8 OILY ABSORBENTS 3 DM ��� <br /> P 352 <br /> w <br /> z 2. <br /> W <br /> G7 <br /> 3. <br /> 4. <br /> 14,5InstructionsandAldhion Mml <br /> fualan <br /> I�WI.PRO�ILEfOR2907M <br /> APPROPRIATE PROTECTIVE CLOTHING ERG#171 <br /> EMERGENCY CONTACT.DAVE CARMCHAEL. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that lie contents oflots conslgnment are fully and accurately described some by the pmpershipong name,and are classified,packaged, <br /> marked and labeled/placarded,and are in so respects In properconcilbn for transpod according to applicable inlarnallonsland national governmental regulations.If expod shipment and I am the Primary <br /> Exporter,I Penny that the contents of this consignment conform to the larmsof the attached EPAAcknowtedgmenl of Consent. <br /> I certifythalthewasne mmimizationslafemem identified in 40 CFR 262.27(a)(if lam alarga quanblygenerator)or(b)(fit smallquanllryge alw)is Ime. <br /> GeneraarslOtiemrs Pdnled(Typ M Slimahue,, Month Day Year <br /> A <br /> F i8.ntemaOonal Stupmenls <br /> ya 1340 1140 <br /> ❑Impod to U.S. LJ Export lm .S. Portmeninvull: <br /> Transpode•signature(for exports oNyk <br /> Date leaving U.S.; <br /> w 17.TmrtspoderAcknwdedgmenl ofRecelpl ofMaledals <br /> TrarepodeI i me ad Name Signature <br /> O Month Day Year <br /> Tromportw me ed Name Si elute Month Oay Year <br /> C <br /> ti <br /> } 18.Discrepancy <br /> 180,Discrepancy Indicate,Space <br /> ❑ Quantity ❑type ❑Residua ❑Partial Rejection El Full Re7eclion <br /> 186.Alternate Facility(01 Genera'.') Manilest Refe ence Number. <br /> U.S.EPA ID Number <br /> U <br /> LL Facilly's Phm se <br /> w 18c.Signature mAhamate Faclltty ar Generator <br /> 4 Money Day Year <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and mcy dag systems) <br /> 3. 14, <br /> l <br /> 1 20.Designa ad FauRy Owner or Opereloc Cedlficelion or receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> nn:edrr Name 8 nature <br /> C 917 /117 <br /> Month Day Vear <br /> EPA Form 6700-22(Rev.3-05) Previous editions are obsole e. <br /> DESIGNATED FACILITY OFC7INATinM ATATF(IF aF011IRF111 <br />