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r <br /> ese print or type.(Form dist d for use on elite(1 2-pitch)typewriter.} i 1� f�-')L` '3�� Form Approved.OMB No.2050-0039 <br /> t <br /> UNIFORM HAZARDOUS 1.Generator ID Num 2,Pap 10( 3.Emergency Response Phone 4. anifest Tracking Number <br /> I WASTE MANIFEST CAR 0 0 0 0 1 6 its e- 0 sob 424-woo aeoud 010197665 JJ K <br /> i 5.Generates Nam and Mailing Address QeneraWs Site Address(if difie erd than mailing address) <br /> MOUNTAM VALLEY EXPRESS CO INC MOUNTAIN VALLEY EXPRESS CO INC <br /> PO BOX 2569 1019 BESSEMER DRIVE <br /> MANTECA CA 95336 MAN€ECA CA 95336 <br /> Generator's Phone: 2 1 ; <br /> 6.Transporter 1 Company NamU.S.EPA ID Number <br /> JS FREMOLJW ENVIRONMENTAL SERVICES INC: G A R 0 0 0 1 7 1 0 1 7 <br /> 1 7.Transporter 2 pang Name U.S.EPA ID Nunter <br /> i� <br /> 8•Designated Facility Name and Site Address U.S.EPA ID Number <br /> GEM OF RANCHO CORDOVA LLC d3a PSC ENV.S <br /> 11355 WHITE ROCK ROAD <br /> RANCHO CORDOVA CA 95712 <br /> Fade 's Pthone: 916 :361-098() <br /> C. A D J 8 0 $ 3 4 1 8 3 <br /> gjj� 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unfi 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity WLfw. <br /> 1. <br /> NON-RCRA HAZARDOUS WASTE,SOLID{OILY DEBRIS, � � L(Ge <br /> � 223 Y <br /> oOn ABSORBENT) <br /> W 2 <br /> 3. <br /> I <br /> s <br /> 4. <br /> 1 � <br /> i <br /> 14.Special Handing Instructions and Addis Inicumation 1)386168 -Otty Debbs ERG#171 <br /> HANDLERS TO BP.4(IHR'rRAIPdEI),%MD USE PPP:. <br /> 15. GENERATOR'SfOFFERQR'S CERTIFICATION: I hereby declare Brat the contents of this consignment are fully and accurately described above by the proper string name,aid are classified,packaged, <br /> marlcacl and labeled/placarded,and are in all respects in proper oonclRion for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify Chat the contents of this consignment oordonn to the terns of the attached EPAAd=vdedgrnerrt of Conte, <br /> I certify that the waste minimization,staternent Identified In 40 CFR 262.27(a)(11 am a large quantity generator)or(b)(d I ern a small quantity generator)is true. <br /> Generatoes/Ofieror's Itk)�dlTyped Name � * / Signature Month Day <br /> Year <br /> 16.International Shipments <br /> F— ❑Ir w to U.S. ❑Export from U.S. Pat of er"wt <br /> Z Traisporter sgrnature(for exports only): Date ng U.S.: <br /> W 17,Transporter rro <br /> rterAcIcwledgmentofReceiptofMater�s <br /> Transporter 1 PrintedlT ad Name Sigrnadxe Month Day YL I r <br /> CL sc <br /> Cf) <br /> Transporter 2 Pdnted/Typod Name Signature Month Day Yea <br /> F <br /> 1&Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 1y ❑Type F-1Reeid. El Partes R*Wot ❑Full Rejection <br /> Marrired Reference Numbs: <br /> 18b_Attamate Facility(or Genera) r U.S.EPA ID Number <br /> GEM has the appropriate} <br /> U<- FaciitifsPhone: W1�� BCOept <br /> Q18c.signature of female FadTdy(a Generator) thi8 genera}Or is Month Day Year <br /> z Wast@ i <br /> r.am 19.Hazadocs Waste Report Management Meow Codes(ie.,codes for hazardous l and recycling systams) <br /> 2. <br /> 1. <br /> 20.Designated Facility Owner or Operator.Celfcation of receipt of hazardous materials covered by rine manlasl excapil as noted in Iters 18a <br /> y Name <br /> Signakae Year <br /> Vff\L q"U- I _ -7 13 <br /> EPA Form 8700-22(Rev.3-D5) Previousedit are obsolete. DESIGNATED FACILITY TO GENERATOR <br />