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Please print or type.(Form designed for use on elite(1 -pitch,.,pewriter.) Form Approved.OMB No.2050-003, UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL0003 1443 1 - ',� -� ; < G B F- 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) CAU FOP A STATE PARKS,CARNEGE SVRC E'" 6600 CORRAL HOLLOW?RCS 704`1' . TRACY,CA 95376 SACRAM NTO,CA 45814 Generator's Phone:925-455-5918 6.Transporter 1 Company Name U.S.EPA ID Number SHOP HAZAR S SOLUTIONS,INC CA000064�3447 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number GEM-RANCHO ANCHc_a CORDs?VA,LLC. t_ACiaBf)8841� 1165 W"TE ROCK RD. RANCHO CORDOVA,CA 95742 Facility's Phone: 916-351-0980 ga 9b.U.S.DOT Description(including Proper ShiT ping Name,Hazard Class,ID Number, W.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. O v /F H — 'Q 1 LU 2. � t. e X 3 Q l /15r 14.Special Handling Instructions and Additional Inform ion PROFILE#401432-01,CASCA-P.D DCiA.E-OUNE/C;,- ERG#128 EMERGENCY CONTACT: 15. GENERATOR'SIOFFEROR'S CERTIFICATION: hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified.packaged, marked and labeled/placarded,and are in all resp cts in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify[hal the contents of this consignr ient conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement ider tified in 40 CFR 262.27(a)(if I am a large quantity generator)„gr(b)(if I am a small quantity generator)is true. Generator's/Offerors Printed/Typed Name Signature ) Month Day Year v `�L� �� l G' r^ •� /�!�-y/� cam._ �� J 16.International Shipments Z ❑Import to U. . ❑Export from .S Port of entry/exit: Transporter signature(for exports only): Date leavina U.S. LW 17.Transporter Acknowledgment of Receipt of Materials LW Transporter 1 Printe ed Name, Signature z Month Day Year G✓G �r/L --_.- L / QZ Transporter 2 Printed(fyped Name Signa re Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: >- 18b.Alternate Facility(or Generator) U.S.EPA ID Number U LL Facility's Phone � 18c.Signature of Alternate Facility(or Generator) Month Day Year F- Q Z � 19.Hazardous Waste Report Management Method Co s(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU LU I 2, 3. 4. r�� ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a d Name Signature Month Day Year FPA Fnrm R7nn-99 lRpv 1-nr�i Pravintic priilinnc arp nhcnlafp