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00204746UPSC 34039415-011%11 <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter) Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> IFEST <br /> WASTE MANCAL000390053 2 (877) 677-2669 002047466 PSC <br /> 5. Generators Name and Mailing Address Generators Silo Address (if different than mailing address) <br /> ORCHARD SUPPLY # 1570 ORCHARD SUPPLY # 1670 <br /> 2650 N MAC ARTHUR DR. 2650 N MAC ARTHUR DR. <br /> TRACY, CA 95376 (209) 662-0192 TRACY, CA 95376 2096620192 <br /> Generator's Phone: <br /> 6. Transporter I Company Name U.S. EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> B. Designated Facility Name and Site Address U.S. EPA ID Number <br /> GENERAL ENVIRONMENTAL MGT LLC DBA RSC ENVIRONMENTAL SERVICES CAD980884183 <br /> 11855 WHITE ROCK ROAD, <br /> RANCHO CORDOVA CA 95742 (916) 351 -0980 <br /> Facility's Phone: <br /> 9d. 9b. U.S. DOT Description (includvig Proper Shipping Name. Hazard Class, 10 Number. 10. Contalners11. Total 12. Unit f3. Waste Codes <br /> HIM and Pactdng Group (if any)) No. Type Quantity Wt.N01. <br /> E <br /> W2, NON•RCRA HAZARDOUS WASTE SOLIDS (OIL, IRON) 487 <br /> 0 2 CW 350 P - <br /> 3. NON RCRA HAZARDOUS WASTE SOLID (EMPTY DRUMS) 512 <br /> 4 CW Soo P -- <br /> tftt9ty �� <br /> 14. Spec al Handing1%fruclions and Additional Information <br /> SHOT LSAN D-04 - ERGO OSHOILSAND-04 - SAND, OIL AND METAL <br /> SHAVINGS (3) OSHEMPTDM•o7 - ERGO OSHEMPTOM-07 • EMPTY DRUMS ( cwTcn_m _ ucnteec w ru 4 <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 International andatonal governmental regulations, If exportshipment and I am the Primary <br /> Exporter I certify that the contents of Oils consignment conform to the terms of the attached EPAAcknowledgment of Consent. " ' <br /> I certdy that the waste minimization statement identified in 40 CFR 26227(a) (l I am a large quantity generator) or (b) (if I am 3�6111 quantity generator) Is true. <br /> generator ?Of erors PrintedlTyp anteigna u"I ay Year <br /> 16. InternationalSh merits1:1Im � to <br /> port ❑ Export from U.S. Part of entrytexit• <br /> Transporter snature fmrex onsonl : Data leavino U.S.: <br /> UJ 17. Transporter Acknowledgment of Receipt ofMatetjals <br /> Transporter I Printedlfyped Name rr i fine oreon ay Year <br /> M Chris Gilliam 12 5 18 <br /> Q Transporter 2 Printedffyped Name Signature Month Day Year <br /> IX <br /> r <br /> 18. Discrepancy <br /> tBa Discrepancy Indication Space © puanii a f Residue ) FJ❑ Partial Rejection i <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) i [ ( 1 <? a � � U.S. EPA ID Number <br /> ...r C <br /> t:! <br /> Facilil s Phone: <br /> w 8c. Signature of Alternate Facility (or Generator) NV9rON n 0EN"FAiL :;p , 1 "t Month Day Year <br /> N19, Hazardous Waste Report Management ttitelhod Codes {i.e., codesfor hazardous waste treatment, disposal, and recycling systems) <br /> 14, <br /> 2 H141 3. H141 ` <br /> 20. Designated Fad6ty Owner or Operator: Certification of receiptof hazardous materials covered by the manifest except as noted in Item 189 <br /> Pri,ledfryped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete, <br /> GENEItATOWS INITIAL COPY <br />