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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gmem a ID Number 2.Page 1 d 3.Errregawy Reaporoe Phone 14.Manifest Tradmg Number <br /> WASTE MANIFEST p _ nnlF;86284 G B F <br /> 5.Gmani Name and Magirg Address Generamfs Site Address(d different than maifing address) <br /> MANTECA TIRE <br /> 201 W EDISON ST <br /> MANTECA,CA 95336 <br /> Gerelalots Phoria: <br /> 6.Transporter 1 Company Name U.S.EPAID Number <br /> SHOP HAZARDS SOLUTIONS,INC CAODODS46497 <br /> 7.Transporter 2 Company Name U.S.FPA ID Nunbar <br /> 8,Designated FaCMy Name and Ste Address U.S.EPA IO Number <br /> GEM-RANCHO iTE CORDOVA,LLC. CAD9809941� <br /> 1105516 ROCK RD. <br /> RANCHO CORDOVA,CA 95742 <br /> FadIU/s Phone: 918-351-OM <br /> 9a. 96.U.S.DOT Devnfo on(nduding Proper Strypirg Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> and Padang G—p('d any)) No. Type 0-01Y Wllbbi. 13.Waste Codes <br /> Ix 1. HAZARDOUS WASTE SOLID,N.O.S.,9,NA3077,PGH. 1 OF P D007 i Bi <br /> o (CHROMIUM)(DO07) <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handfig Insbumans and Additional Information <br /> kM-PRORLE#445705-01,METAL SHAMNGS HATH CHROMUM, ' / <br /> 1 <br /> APPROPRIATE PROTECTIVE CLOTHING ERG#171 EMERGENCY CONTACT: �Fl f is V,cu �� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedam that the contends of this rasgnment am"and acaunely described show by the proper shipping name,and are classified.packaW, <br /> marked and labeledipmrarded,and am in all respects in proper condAian fim bansport acmoing m appligbie international and national gammmental regulations.If export shipment and I am the Primary <br /> Expwmr,I wtry that the contents of this consignment conform m the terms of the arched EPA oclgmml of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quandry generator)or()('dl am a smati quantity materi is true. <br /> Geremlo/s108emrs PnnWffyped Name "Agnates Month Day Year <br /> h <br /> F 18.thlemetional Shgnenb ❑Impodm U.S. ❑Export from US. Portafenhymdt <br /> = Transporter sigrawre(for exports only): Dateleaving U.S.: <br /> w 17.Trarsporteredumledpneidd Receipt oFMaMials <br /> y". Transporter Pmwffyped N Sgremm Month Day Year <br /> o°. O <br /> N <br /> Tr 2 PrhteM Name SWMM Month Day year <br /> 1 18.Dbcremarcy <br /> I 18a.Disrreparcy Indrman Spam ❑ ch mbty' ❑Type ❑Residue ❑Partial Rejecfion ❑FW R*d. <br /> Manifest Reference Number <br /> Z 18b.Altemate Faniity for Cxmemtor) U S.FPA ID Number <br /> J <br /> V <br /> LL FaWs Phone: <br /> aw lk SignammolA6emate Facility la Generator) Month Day Year <br /> 2 <br /> 19.hazardous Wash Report Management Method Codes(i.e.,codes for hazardous easm treahnm4 disposal,and lecydhg systems) <br /> 1. 2. 3, 4. <br /> 20-Des nated Facility Ds o,Operdor Cerebron ofreeeiptdtavourdDus mammals mvaed by themmimamrept ae noted in Bem/8a <br /> PirfladiTyped Name Slgmeee Month Day Yaw <br /> EPA Form 6700.22(Rev.305) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />