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Please print or type.(Form designed for use on elifle(12-pitch)typewnter-) Form <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pagejof3.Emergency Response Phone .Manifest Tracking Number <br /> WASTE MANIFEST CAL000298176 1800-746-7448 1003235838 JJ K <br /> 5.Generator's Name and Mailin Address Generator's Site Address(if different than mailing address) <br /> SB GAS-8 MARI¢T <br /> 515 W 1.1th STREET <br /> TRACY,.CA 95378 <br /> Generators Phone: 510-388-9924 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SHOP HAZARDS SOLUTIONS CA000OU6497 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.De i�ffW Facilintp a adSitWiddrass.LL U.S.EPA ID Number <br /> 11855 WHITE ROCK RD:, CIAD980884183 <br /> RANCHO CORDOVA.CA 9574 <br /> FacAlitys Phone: 918•'351-0980 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Padang Group(d any)) 13.Waste Codes <br /> No. Type QuantityW[.Nol. <br /> 1 HAORDOUS WASTE SOUD,N.O.S.,9,NA3077,III(BENZ NE. 1 DF T O P D018 352 <br /> o GASOUNE)(D018) . <br /> w <br /> z 2. <br /> w <br /> U' <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions agdAdditional Inforr iaton <br /> PRORLE#R' GASOUN PUMP FILTERS,HOSES 8 ABSORBENT PADS <br /> APPROPRIATE P OTEC E OTHING <br /> SEE ERG#171 VV I <br /> ID <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION I hereby declare that the contents of this consignment are fuly and accuretety desc bed above by the proper shipping name,and are classified,Xckaged, <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 oonsigitment contort 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)(d I am a large quantity,generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Sign to Month Day Year <br /> �� O 3 I I9 0 <br /> _j 16.Intemational Shipments Import to U S. <br /> po ❑Export from U.S. Port of entry/exit: <br /> 2 <br /> Transporter signature for <br /> P 9 ( exports only): Date leaving U.S.: <br /> 17.Transporter AdmoM4edgment of Receipt of Material <br /> Tran 1 Printed7T Name Si to Monty Ye <br /> a Y Cw 4 1-3 <br /> N <br /> Q T sporter 2 nnledlTyped Na 'Signature— Month Day Year <br /> oc <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space � ❑ ❑ ❑ 1 ElFullRejection <br /> ❑ Ouan T Residue Partial Rejection <br /> Manifest Reference Number <br /> 18D.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facflitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 1 1 I 2. <br /> 20.Designated Facility Owner or Operator Certificatior o receipt of hazardous materials covered by the mardest except§Wed in I 18a <br /> Printed7Typed Name Signature Month Day e <br /> I UL 3 <br /> EPA Form 6700-22(Rev. P ous editions a fete DESIGN E CILI T DESTINATION STATE(IF REQUIRED) <br /> 10308.1409 <br />