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ML V L IV L V-r 4 V <br /> CC: MANIFEST BOOK/AIP ✓ r ; <br /> or <br /> 9pA. Adee(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 75- <br /> NIFORM HAZAR OUS era or umber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST t_AL00110359 o ? % G B F <br /> 1 011(-746"+ 449 <br /> Generators Name and Mailing Address <br /> ruFF ao'Y INC. Generator's Site Address(if different than mailing address) <br /> . <br /> 5151 E ALMONDWOOD DRIVE <br /> F MANTECA,CA 95337 <br /> .� <br /> Generators Phone2-09-23&1361 <br /> 6.Transporter 1 Company Name <br /> o SHOP HAZARDS SOLUTIONS.INC U.S.EPA ID Number <br /> --� <br /> 7.Transporter 2 Company Name CA0000846497 <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> GEM-PANCHO CORDOVA,LLC U.S.EPA ID Number <br /> �} 11855 WF#TE ROCK RD. CADQU I9464IEc3 <br /> J� RANCHO CORDOVA,CA 95742 <br /> Facility's Phone:916-351 0geO <br /> ga_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> J HM and Packing Group(if any)) No Containers 11.Total 12.Unit <br /> No. Type Quantity Wl.Nol. 13.Waste Codes <br /> 1. - COUS WASTE SOLID <br /> ABDM P 22:3 1352 i <br /> ABSORBENTS B CAL <br /> a <br /> w --�— <br /> z 2.LU <br /> GEM has the appropriate I <br /> and will accept - r -- <br /> 3. rn I <br /> +ho wa.qtP this generator is <br /> 4 shipping. 1 ) <br /> I _ <br /> 14.S Baal Handlin Instructions and Additional Information ) 1 <br /> �ROALE#� .20:342 <br /> APPROPRIATE PROTECTIVE CLOTHING <br /> SEE ERG#171 <br /> 5� ss <br /> r7�ERATOR'SIOFFEROR'S 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 /> ed 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 /> rter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> fy that the waste minimization statement identified in 4n CFR 26Z27(a)(ifI ama large quantity generator)or(b)(iffama small quantity generator)is true. <br /> erators/O feroes Pdnled/iyped Nanle Signature Month Day Year <br /> J 16.International Shipments /''*/��� Z U <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> C27 <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> X Transporter 1,Printedrryped Nam Signature <br /> O /_' _ Month Day Year <br /> CL G✓� e 'fI7/�TA/ <br /> QTransporter 2 Printed/ryped N me Sign ure <br /> Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> 1 ❑Full Rejection <br /> Manifest Reference Number: <br /> F 186.Alternate Faaliry(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> LLI <br /> 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> Month Day Year <br /> �ME I I <br /> 0 19Hazardous Waste r <br /> aste Report Managemeid Method Codes(i,e.,codes for hazardous waste trealment,disposal,and recycling systems) <br /> oil. I 2. 4 <br /> HN <br /> 20.Designated Facility Owner or Operator:Ce ficalion of receipt of hazardous materials covered by the manifest excepl,.gs noted in Item 18a I <br /> ed7Typd Name E <br /> Signature Month Day Year <br /> ( &, i &\o L <br /> EPN Form 8700-22(Rev.3-05�Previous editions are obsolete. .��\ j,/�, <br /> �/�f DESIGNATED FACILITY TO GENERATOR <br />