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Please print or type.(C=orm des' I !)r use on elite(12-pitch) ypewritor.) Form Approved,0 MB No.20500039. <br /> 1. <br /> - " <br /> UNIFORM HAZARDOUS 1.7,]:,nerstor ID Number 2,Page I of 13,Emergency Response Phone 4,Mandust Trucking Number <br /> WASTE MANIFEST (_1'5L?0 4/ 1 916-649--(144 003727941 JJK- <br /> S.Generators Name ano mailing At:ircu Gunsfatoi's Sft AddrBw(I oftreni Man malting address) <br /> z <br /> Generators Phone: (e 7. <br /> fl..Transpoftr I Comp;ny Namq U.S.EPA 10 NumW <br /> SACUKENTO WASTE UIL CAL 913 334 VIA" <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Fadlity'Namet and Sft Address U.S.EPA ID Number <br /> GUM - IRANC4ill) CGVX)VA LLC <br /> 11855 WHITE ROGE ROAD. RANCKQ WRDOVA, GA 95742 <br /> Fariltlys Phone; 9:1 `)' 351-0980 CAD 980 884 183 <br /> 9a. Do.U.S.DOT DoacrPrion(i- luding Proper Shipping Namc,Hazard Gleazt,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and PacKirg Group any)) No. Type QuanYy WLA/oi, <br /> I -1. .. Ir �� .,, <br /> Ix 1W)N—RCRA "�,'LRWUS rviAS.E SOLIDSOI.i.�i —7 <br /> C3 <br /> UJI <br /> M 2. <br /> LU <br /> 3 <br /> 4. <br /> 14.Sp4WI Handling 177W-ns at,i WdMonal friformalon <br /> �WNOLEFRS IVID PL 1 Z-AINED AIND JSI: PPE <br /> 15. GENERATORVOfFEROR'S ATIFICATION"lheireDy dedare treat Me contents of this consignment are fully and atowiRdy describcd aboyo by the prvM shipping name,oriJ ofe ckmdlaKi,packaged. <br /> marked and labeled/placarded ,d are in al respects in proper condition for transport according to applicable Intematlonal and national govemmenial.regulations.If export shipment end I am the Primary <br /> Exporter,I cwtry that the conto %or this convignment oonform to the terms of Me atbefta EPA AcKnowe(igment of Consent <br /> I car*that the waste minimiz:ion statement identified in 40 GFR 262.77(a)(if I ant a large quantity generator)or(b)(if I am a small qua"generator)it true. <br /> FCen,e--,1n,tWA1Off&mes Printed[Typed I j I meSignatu Warith Day YOZ <br /> 1:D e- <br /> --jj 1 inigmational Shipments ---1. ❑ 9f- <br /> ripo r,to U 5 Export"M U.S. <br /> Transporter signature(for exports o: Dale leaving U.S,. <br /> Of 17.Tr-aispor.%rA,-,kr)oWedgnlPntofl; 1xiP1,11viateriais <br /> LIJ <br /> � <br /> Transporter' <br /> : printed�ped Name 6ignatjR Mord Day Year <br /> 0o <br /> T, + .4 <br /> X Transporter 2 FrintadfTyped Name5gnafule Month Day Year <br /> a.Disarepancy <br /> 18a.Ci3crepancy Indication Space ❑ Quaflaw ❑Type ❑Resldu,3 El Partial Rejection� ❑Fu11 Re*don <br /> Manlfest Reference Number. <br /> >- 18b.Alternate Facility(or Gafleral6i" U.S.SPA 10 Number <br /> Facility's Phone: <br /> Day Year <br /> 19.Hazardous waste Report Manaj rent Method Codes(i.e.,codes for hazardous waste treatment disposal.and recycling systems)&a <br /> UJI 1 2. 4. <br /> C3 <br /> 20.Oesignated Facility OW"Cf or Op Wr.Cert&awn of receipt of hamrdoup mater4ft covered by the mande4except aa,nolud in,Rom 18a Y <br /> Pdnted7yped Name Signature Montri Oay ear <br /> EPA Form 9790-22(Rev.3-05) Pro),I is editions are obsolete. GENERATOR'S INITIAL COPY <br />