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Please print or type. (Form desgrted for use on elite (12-pitcl <br />UNIFORM HAZARDOUS 1' Generator ID Number <br />wASTE MANIFEST CAL000251953 <br />5. Generators Nan* and ging Address <br />a G C Painting Solutions <br />107 Val Dervin Pkwy <br />stockton, CA 95206 <br />Generators PIS: 0 8 - <br />6. Transporter 1 Company Name <br />General Environmental Manal <br />7 Transporter Company Name <br />t. Inc. <br />2, Page 1 of 3. Emergency Response Pty <br />2 (800) 326-1011 <br />Generator's Site Address (if different than <br />8. Designated Facility Name and Site Address <br />(AM Rancho Cordova, LLC <br />11855 White Rock Rood <br />Rancho Cordova, CA 95742 <br />Facility's Phone: 916 351 0980 <br />9a. 9b. U.S. DOT Dewipbon (-.dmg Proper Shipping Name, Hazard Class. ID Number. <br />HM I and Paddng Group Id any)) <br />RQ UN1993 iriaa e Fble 1 quids, n.o.s., <br />Coe X 3, 11 (Paint thinner) (101001) <br />a <br />WZ as e E e qu da, n.o.s., <br />UJI 0 X , II (Gasoline, Diesel) (D001) <br />Q NA3077 hazardous waste, solid, n.o.s., <br />, III (aarium sulfate, <br />lycid-i-cyanurate)(DO05) <br />on—RGRA hazardous waste liquid (Nater <br />ased Paint) <br />10. Containers <br />No. I Tyle <br />_203 Form Approved. OMB No. 2050-0039 <br />4. Manifest Tracking4, Manifest Tracking Number <br />0008��� GBF <br />iailinq address) <br />CAD983649880 <br />.S. EPA ID Number <br />U.S. EPA <br />CAD980884183 <br />11, Total 12. Unit 13. Waste Codes <br />Quantity Wt.Nol. <br />001—PA 0 q uv P <br />061 PM D;UU p <br />1) 86108 : 128 t l x 7� ) <br />830245 : 128 <br />9b3) 86435 ( 3 xe96 ) <br />9b4) 86732 ( x ) <br />15. GENERAT0R'StOFFER0R'S CERTFICAT I declare that the contents of this consignment are fey and acaratety described above by the proper shipping name, and are classified, packaged, <br />marked and labeledipfacarded, and are in all respects in proper condition for transport a000rdin9 to applicable international and national governmental regoations. If export shipment and I am the Primary <br />Exporter I certify that the oonlarft of ft consoynent conform to the terms of the attached EPA Acknowledgment of Consent. <br />identified n 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if I am a small quantity generator) is tnx . <br />I certify that the � MAonth Day <br />C rators10fferors yped ►dame . - . Suture . /l .` . �� /j 7( -) i, <br />-j 16-kilISM8500011 shim -Its of <br />to U.S. Z U ExPort from U.S. Pon of entry/exit <br />1- Date leaving U.S.: <br />= Transporter signature (for exports only): <br />W 17. Transporter t of Receipt of Matte th Day Y <br />;n Z <br />T er 1 Prinied/Typed Name <br />Morndn Day d <br />Q PnrntedrTyped Name <br />tY <br />t- <br />16. Disaepatcy <br />18a. Space ❑ Quantity ❑ Tye ❑Residue ❑ Partnl Rejection ❑ Fu! Rejection <br />Manifest Reference Number <br />U.S. EPA ID Number <br />18b. Alternate Fly (a Gator) <br />J <br />V <br />tis+ Facilitys Phone: Month Day <br />w 18C. <br />Signature of Alternate Facey (o Cool <br />4 <br />0 Method Codes (.e., codes waste treatment, disposal, and recycling systems) <br />N 19. Hazardous Waste Report 3. 4. <br />w 1 2. <br />0 <br />20. Designated Facility Owner or Operates Certficabon of recorpt of hazardous materials covered by the manifest except as nded in ttem 18a Month Day <br />Printed/Typed Name Signature <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />nCclI2W a1'ci1 c®f"!I 1'T1/ TIf1 HCCTlIfla cTaT1S HG QCAI tiQCrt91 <br />