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` alanerater,ma4 a 4 3o:DTSD,P.C.BOY 4M,Saar Mehto,CA 8: 40,4W'Amnin zoo cat's -- <br /> Please print or type.(Form designed for use on elite(12-puce)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST CARL301DOSM72 � - 1-wD-424- = 009444607 JJ K <br /> 5Generatto{r's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 213 L �38D0 ST <br /> STOCKTON,,C,,A 9520 <br /> Generator's Phone: x-982-5758 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> EVERGREEN.ENVIRONMENTAL SERVICES CAIDN2413262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> GEM.OE RANCHO CORDOVA LLC DBA PSC ENV. SER: <br /> 11855 MM TE ROCK ROAD <br /> CAD8808841 B3 <br /> RANCHOCORDOVA CA95742 <br /> Facility's <br /> Phone: QjK351-09bld <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> c UN1479,WASTE 0XICIONO SOLK),N.Q.S.,5.I:12 .' 551 DWI <br /> X I DM2. � <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> A. 71295 ERG 140.9b1: Document# <br /> 121359 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I here4,daclare That the c.;nte;rs of this consignment are fully and accurately described above by the proper shipping name,arxi are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport acr.:,rding to applicable intemstional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the torr^.;of h.;• <zim,61 c?Arlcknowledgment of Consent. <br /> I certify that the waste minimization statement identified',•6 CFR?=2.27(a1(tf 1 rn a large quantity generator)nr(b)(if]am a small quantity generator)is true. <br /> C�eCaeratorsl gfferors Prinied�Yry7p�ed Nam/e� ` Signaiure C, <br /> Month I Day Year <br /> J` J <br /> ri 16.Internationid Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter IPri ed/TypedName Si `//�//��►�� Moonntthh_�J/ Day Year <br /> /( <br /> Z Transporter 2 Printedffyped Name Signature C/ Month Day Year <br /> fr <br /> 18.Discrepancy 1 <br /> 1 Ba.Discrepancy Indication Space ❑ quantity El T,roe ❑Residue ❑Partial Rejection ❑Full Rejection <br /> _ Manifest Reference Number. <br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> Q 1 2. 3. 4. <br /> - ] <br /> EPnnped <br /> nated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. 7ESIGN,ri ED FACILITY TO DES a INA,1 ION STATE (IF REQUIRED) <br />