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.. Q <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050_003 <br /> UNIFORM HAZARDOUS 1.Generator ID Number =0(fl . Response Phone 4.Manifest Tracking Number <br /> 3 FLE <br /> WASTE MANIFEST 01 n 7 8 8 4 <br /> 5.Generator's Name and Mailing Address Generator's ite A'dress if different than mailing address) <br /> {office Max #6;298 Office Max#6298 <br /> 2099579771 4733 Quail Lakes Chive 4733 Quail Lakes Drive <br /> Generator's Phone: 5a07 r-4fnn_ M__ 14C.P07St <br /> 6.Transporter 1 Company Name U.S.E A ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address General Environmental Mgt. LLC U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova. GA 95742 <br /> Facility's Phone: <br /> , 916,351121191912 1 roDs 884183 <br /> 01 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> a 1,#ion RCRA hazardous waste, solid (Cgs STATE 1 CF wool P 33 <br /> RE LATER. IDS), <br /> 2. <br /> L <br /> ca <br /> 3. <br /> 4. <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> i. 102343(GA State Regulated Organic Containing Solids) <br /> 15. GENERATOR'SIOFFEROR'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 intemational 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) <br /> Month ay Year <br /> e' eros noted yped m <br /> 1 <br /> 16:international Shipments E Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter s' nature for exports only): Date leaving U.S.: <br /> It 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature <br /> ont ay Year <br /> I <br /> cc Johnny Harner Month ay Year <br /> z Transporter 2 Printed/TypedName igna a <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ..r <br /> V <br /> Q <br /> u- Facility's Phone: <br /> Ck <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> } 90 4.2. 3. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name 0 <br /> Signature Month Day Year <br /> IN 1171 <br /> f <br /> EPA Form 8700- ev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATIO[d STATE{IF REQUIRED) <br />