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L. <br />Fnrm Annrnved. 0Mf3 No. 2050 0039 <br />Et A form tsm-a (Kev. 3-uo) v Zu <br />s eomons are oosoie[e. DESIGNATED FACILITY TO UCNit:IiA.I UK <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />ITPageTotTY <br />Emergency Response. Phone <br />' <br />4. fAanlfest,Tracking Number <br />JJ <br />WASTE MANIFEST / <br />1 <br />916-�$49-0144 <br />5. Generator's Name and Mailing Address r Generator's Site Address ('rf. different than mailing address) <br />/ <br />ex Q" <br />yw g <br />Generator's Phone: . <br />6. Transporter 1 Company Nae VS. EPA ID Number <br />SAC ENTO -WAST& QIL ,< CAL 913 534 912 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />-8-.Designated-Faoility-NemeandSitsAddress <br />GEM — RANCHO CORDOVA LLC <br />11555 WHITE ROCK ROAD, RANCHO CQ VA, CA 95742 <br />916-351®0950 CAD 980 884 183 <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Desorption (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any)) <br />Quantity <br />Wt.Nol. <br />1. <br />^9 <br />� <br />� <br />ce <br />NON—RCRA HAZARDOUS WASTE SOLID <br />(OILY SQILDS) <br />� <br />400 <br />P. <br />Z <br />2. <br />W <br />C9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />HANDLERS TQ BE u <br />�'RTNEA AND USEEP3'E <br />-3..'Rkk�'�''�y�'�a�°�-ti;- c.�:� =-- `�-.tc _,P>ISa _. _.-�_ �-i.._.e_ sl/_rz.: .✓.. ...,_..v.., ,. /� r%...�4>%. � :�ii_ .t.!', <br />ERG '08 0171 <br />15. GENERATOR'S(OFFEROWS;CERTIFICATiON: I hereby declare that the contents of this consignment are fully and accurately 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 intemational 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 EPAAckhowledgment 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) (iffl am a small quantity generator) is true. <br />Generatoes/Off6mes Prntedfryped Name Signature .r Month .Day. `Year <br />A 1A <br />-1 <br />~ <br />16. international Shipments <br />❑ Import to U.S: ❑ Export from Port of entry/ed: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printedrryped Name Signature Mon Day Year <br />1 <br />1/0 fr <br />Co <br />QT <br />so er n ed/T ed N Signature Month Day Year <br />h <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facliity(or Generator) U.S. EPA ID Number <br />uQ <br />Facility s Phone: ; <br />W <br />18c. Signature ofNtemate Facility (or Generator) <br />Month Day Year <br />�Q1 <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1 <br />2,. 3. <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedffyped Name Signat/urs �% Month Day Year <br />Et A form tsm-a (Kev. 3-uo) v Zu <br />s eomons are oosoie[e. DESIGNATED FACILITY TO UCNit:IiA.I UK <br />