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Please print or type. <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking NumberForm oved.OMB No.2050-0039 <br /> WASTE MANIFEST CALt �14 000401815 1 F L E <br /> 5.Generator's Name and Mailing Address t ' ) X77�+�69 <br /> Generator's Site Address(if different than mailing address) <br /> Marshalls #MG122 ��: <br /> ( 09) 952-787 Marshalls#M��122 <br /> 2203 Grand Canal Marta Grand Canal <br /> Generator's Phone: ;t ockt ars, CA 95207 <br /> 6.Transporter 1 Company Name Stockton, CA ` 52 r <br /> U.S.EPA ID Number—,.,,' ; <br /> Sterieyele specialty Waste SoInc �_ � <br /> I.Transporter 2 Company Name "--001,10 24 <br /> U.S.EPA ID Number <br /> y <br /> 8.Designated Facility Name and Site Address <br /> General Environmental Mgt, LLC U.S.EPA ID Number <br /> 11855 White ROck Road <br /> Rancho Cordova, CA 95742,Hazard assID Number <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping NameHazd Cl , , Containers <br /> . onta <br /> 9a. 10Ci <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> o X t 1950; Waste Aerosols 1, ERG#126 1 CE 0009 F° 331; )?OO# <br /> w <br /> Z 2. <br /> w <br /> 3. <br /> f <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> 1a 1023,su(Aerosals, Flammable) t'T <br /> 15. GENERATOR'S/OFFEROR'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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Genera�r fferor's Printed/Typed Name <br /> ;111 \ Signature ont�Aalf of T Month Day Year <br /> J J iQ fL L�,, 1 ) ; <br /> 16.International Shipments 4 <br /> Transporter signature(for exports only): �- <br /> ❑Import to U.S. ❑Export from U.S. Port ofentry/exit: <br /> ? <br /> of 17.Transporter Acknowledgment of Receipt of Materials Date leaving U.S.: <br /> LU <br /> 11— Transporter 1 Printed/Typed Name <br /> Signature <br /> a Demarco Pr~odnax Month Day—Year <br /> Z Transporter 2 Printed/Typed Name i •� <br /> Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> F}— 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> La 18c.Signature of Alternate Facility(or Generator) <br /> Z Month Day Year <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except a <br /> ypeain Item 18a <br /> Printed/Td Nme <br /> Signature Month Day Yr <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> DESIGNATED FAC Y TO EPA's a-M E YSTEM <br /> [7�Di7.tA... 'y i-..."i nw )-rS A.S.S�-�i tle ro+t—.�....a_ ,.,, ter.... ..-+a... •� <br />