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Please print or type.(Form designed for use on elitehit <br /> 12- cewriter. '1�111��'�'� � <br /> ( p )typewriter.) Form Approved.OMB No,2D50- 039 <br /> UNIFORM HAZARDOUS I 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest TraW Number <br /> WASTE MANIFEST AL000.374257 8775772669 008 80341 F L E <br /> 5.Generator s Name and Mailing Address Generator's Sile Address(t different Than mailing address) <br /> °D11ar Cefte/-al ##-y5�� t int t n #1 � <br /> �+X�) 2 82.3 1 4 ;60 _NORTH MAIN STREET `w` �tv .- � F'��IN -FREET <br /> (^� GeneralVs Phone- Mt'NTECA, CA 95336-33+x30 f MAN EC—Ay C"A 95336-3300 <br /> 6.Transporter tompany Name <br /> U.S EPA ID Number <br /> eF°icy le Specialty esti_ S-Olutiorls 1Ctt r <1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8-Designated Facility Name and Site Address General Environmental Mgt, LLC IU.S.EPA toNumber <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 35742 <br /> Facilit sPhone:g163.51098Q ^Ala $0Q8r41 d { <br /> 9a. 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/Vol. <br /> - Non RCRA hazardous waste, liquid (Consumer i CR' 00008 R 331 <br /> o Products), <br /> Z 2. <br /> LU <br /> 0 <br /> 3- <br /> 4. <br /> 44:Special Handling Instructions and Additional Information 1, 110524(Non—RCRA Liquid Waste (CA Only) — L o o s e pac k) <br /> 15. QEKMTOR%K*TEf='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 /> marked 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 /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(t I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> sPrinteW7yW Name Month Day <br /> ear <br /> C a v, �1V1 j 1 1.50 <br /> J .IMemahorral$11r ERtS // - - <br /> Z ❑Import to U.S. ❑Export frafn Portof entry/� <br /> T signature er for only): Da4eavint�U.S.: / <br /> a 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name turu Mont ay Year <br /> 0 Anthort;r hack <br /> 1-3 V-017 <br /> Q' Transporter 2 Printe yped Name nature th Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type FJ Residue E]Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> U <br /> LL Facl s Phone: <br /> r18r.S posture of Allemate Fadtity(or GeneraW) Month Day Y r <br /> a <br /> rn 19.Hazardous Waste Report Management Method Cutlet(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' r 2- I3. <br /> r �4. <br /> 20.Designated FaafAy Owner or Qperalor Ceriftaton of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnIttedjr—Name Signature Month Dsy Year <br /> EPA Form 870 2 ev.3-05) Previous editions are obsolete. (� � <br /> DESIGNATED FACIL!T Y TO DESTINATION STATE(IF REQUIRED) <br />