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.. 7 4-e C�) <br /> 4 lq � <br /> f3 � Q35 <br /> Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form' Approved.roved.OM8 Ni 2050.0038 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 11 80ID-7411i 000897727 G B F <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> INTERSTATE TRUCK CENTER 645 NAVY DR. <br /> P.C.BOX 11 6 <br /> STOCKTON.CA 95206 TOCKTON,CA 95206 <br /> Generator's Phone <br /> 6.Transporter 1 Company Name U.S.EPA tD Number <br /> SHOP HAZARDS SOLUTIONS,INC CM00OU0497 <br /> 7-Transperier 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 11GEM-RANCHO M OC4 KCRD A,LLC. CADMIN11 E3 <br /> RANCHO CORDOVA,CA 95742 <br /> Faclligrs Phone: 01111,,3511-01W <br /> ga. 9b.U.S.DOT Descripbon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity WiJVoI, <br /> 1. W'astigAemsvls,flammalsle,(III niatemIeding I LCaPecM.2.1, ,1+ DM j"469-- P D001 331 <br /> 0001) 33d <br /> W <br /> Z 2. <br /> W <br /> 3. <br /> d. <br /> 14.Special Handling Instructions and Additional Information <br /> PROFILE 087521,MSC SPENT AEROSOLS,ERG#126 <br /> APPROPRIATE PROTECTIVE CLOTHING <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurateiy described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I ceruty that the waste minimization statement identfred in 40 CFR 262.27(a)(if I am a large quantity generator)or(b m a small quZ generaloo is hue. <br /> Gene rslO;Zidn yped Name Signatur Month Day Year <br /> d <br /> --. 1 In ions en <br /> N ❑Import to U.S. ❑Export from U-S. Port of en',rylexit: <br /> z Transporter signature(Por exports only): Date leaving U.S.: <br /> w 17.Transporter Ac$tnowiedgment of Receipt of Materials <br /> TranTai 1 PrintedlTyped Name Sin to Month D Year <br /> QIP' ! .U. <br /> Q Transporter 2 PnnteNT Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑T EJResidueType ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b,Alterrale Facility(or Generator) U.S.EPA l➢Number <br /> J_ <br /> LL. FacilitysPhone: <br /> C3 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> f19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> I. �, f ` 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest exce as noted in Item 18a <br /> Pi d Name r Signature fMoonth Day Year Year <br /> UJO 5-�j 14 <br /> V CJ 0 <br /> EPA Form 8700 22(Rev.3-051 Previous editions are obsolete. <br /> G11 D5 <br /> 5 74.r1595 <br /> ` DESIGNATED FACIL TO DPESTIMATION STATE IF REQUIRED) <br />