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please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EpAForm 8700-22(ftev.3-05) Previous editions are obsolete, DESIGNATED FACILITY TO D99TINATION STATE (IF REQUIRED) <br />yk <br />$v:.-, <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />i> .J� �Ca f 5 S <br />2. Page i of <br />1 <br />3. Emergency Response Phone 4. <br />916-344-1434 <br />Manliest Tracking Number <br />006629657 JJ <br />WASTE MANIFEST <br />rrA Z <br />5 Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Ac1z,te "ril-vcl Pct fs �4 <br />iU.Lty CJ 15` ""V 5 f,C1t'Jr' Gf2-q SZC i <br />Generators Phone: 110Iq �� � " -ZO Z I f <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SACRAMENTO WASTE OIL CAL 913 534 912 <br />7. Transporter Company Name U.S. EPA ID Number <br />8 Designated Facility Name and Site Address U.S. EPA ID Number <br />GEM — RANCHO CORDOVA LLC <br />11855 WHITE ROCK ROAD, RANCHO CORDOVA, CA 95742 <br />Facility's Phone: 916-351-0980 CAD 980 884 183 <br />ga <br />9b. U.S. DOT Description (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 />Hh, <br />and Packing Group (if any)) <br />Quantity <br />M.Nol. <br />1352 <br />7.23 <br />(I/ <br />o <br />NON—RCRA HAZARDOUS WASTE SOLIDS <br />(OILY SOLIDS) <br />z <br />2. <br />LU <br />0 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />HANDLERS TO:BE TRAINED AND USE PPE <br />ERG 08 #171 <br />15. GENERATOR'SIOFFERORIS CERTIFICATION: I hereby declare that the contents of this ccinsitinatent are fully arid-iiccuirately described above by the propershipping name,'aIppre classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export ship marit and f am the Primary <br />Exporter, I certify that the contents of this consignment cordorm to the terns of the attached EPAAcknowledgmenf�i ;GoJiserit. <br />I certify that the waste minimization statement identified 1n40 GFR 262.27(a) (if I am a large quantity genera; _Iti}'(if I am a small quantity generator) is true. <br />GeneraloesfOffemes Printed(ryped NameSignaiu Month Day Year <br />� ff <br />I �/ J/ yD <br />LA,- &'L, I <br />, C/ <br />—r <br />I.- <br />16. International Shipments <br />❑ import to U.S. ❑ Export from U.S. Port of errirytexit: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. TransporterAcknoxaedgment of Receipt of Materials <br />Transporter 1 Printed yped Name Signature Month Day Yea <br />t U <br />a <br />t �. � V `P 3co <br />I� <br />Transporter 2 PrintedlTyped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space 11 Quantity ❑ Type ❑ Residue 0 Partial Rejection ❑ Full Rejection <br />i <br />Manifest Reference Number: <br />F- <br />18b. Alternate Facility For Generator) U.S. EPA ID Number <br />U <br />LL- <br />Facility's Phone: <br />u0, <br />18c. Signature of Aftemale Facility (or Generator) <br />Month Day Year <br />ti <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyding systems) <br />4 <br />1. <br />14 11 <br />2. <br />3 <br />4 <br />20. Designated Facility Owner or Operator Cerlification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Sicnature Month Day Year <br />Printed�vPed Name r ` 1JT,—,, <br />G, { n � l anl9 ' i C , ! / Z 1, <br />EpAForm 8700-22(ftev.3-05) Previous editions are obsolete, DESIGNATED FACILITY TO D99TINATION STATE (IF REQUIRED) <br />yk <br />$v:.-, <br />