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Please Drint or tvDe. (Form desinned fnr use on elite 119-nitrhl tvnouiritcr ) <br />( DESIGNATED FACILITY TO GENERATOR <br />Ful uinNNiuvctu. viviD wD. [VDU-UU3y <br />HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />T[U:NI:FORM <br />pp <br />ASTE MANIFEST O 1 G I� F <br />.Gnerator's Name and Mailing Address enera or's Site Address (if different t an mailing address) <br />SYSTEM TRANSPORT. TWT,E. <br />707 E. ROTH RD. <br />CAMP, CA, 95321 <br />Generator's PhoneFRENCH <br />. � <br />JUN 2 7 2 Q <br />13 <br />6. Transporter 1 Company ame U.S. EPA ID Number <br />;HOP HAZARDS SOLUTIONS, INC E 1 TA I <br />7. Transporter 2 Company Name U.S. EPA ID Number HEALTH DEPARTMENT <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />GEM -RANCHO CORDOVA, LLC. <br />11 t r �ir3 1 t � <br />865 VM TE ROCK RD <br />RANCHO CORDOVA, CA 9'5742 <br />Facility's Phone: 1 s X5'1 0€i[3 <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />0: <br />1. NON-RCRA HAZARDOUS WASTE SOLID <br />DAA <br />955 <br />P <br />223 <br />Fo <br />ABSORBENTS, COIL 8 DIESEL <br />_M . <br />W <br />W <br />2. NDN' �C11Aq�AAW*eJ;L4b <br />75- <br />3. <br />i <br />e.._._ ----- <br />I <br />4. <br />14. Special Handling Instructions and Additional Information <br />PROFILE #GR 11 `?77-01 <br />APPROPRIATE PROTECTIVE CLOTNNG <br />FEE ERG #171 -. _ <br />ff .".Lo :F. <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: j hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and ar classified; packag d, ' <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity gene tor) is true. <br />G erator's/Offeror's Printed/Typ N <br />Name M{{ontth Day Year <br />KA e <br />1 S4 <br />j <br />zImport <br />16. International Shiftents <br />to U.S. ❑ Export from .. Port of entrylexit: <br />- <br />Transporter signature (for exports only): Date leaving U.S.: <br />W17. <br />Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 rinted(fyped Name Signature Month Day Year <br />r <br />QTranspo <br />er 2 nn ed yped Nae Sign ure Month Day Year <br />F- <br />18. AJscrepancy .:. <br />18a. Discrepancy Indication Space <br />❑ Quantity 1:1 Type ❑ Residue L1 Partial Rejection El Full Rejection <br />GEMg� <br />has the approprla pnifestReferenceNumber: <br />18b. Alternate Facility (or Generator) permits for, a n ��� accept U.S. EPA ID Number <br />_J <br />the waste this generator is <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) shipping, Month Day Year <br />Q <br />Z <br />49. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. 4jj <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the m`a ifest except as noted in Item 18a <br />Printedrryped Name fgnature i Month Day Year <br />t <br />( DESIGNATED FACILITY TO GENERATOR <br />