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Please print or type. (Form designed for use on elite (12-Dit6hl tvoewriter.) <br />I (I 6��' �)' '(-4j, i <br />V DESIGNATED FACILITY TO GENERATOR <br />NON -HAZARDOUS 1. Gaamrator ID Nmnber <br />2. Page 1 of <br />3. F..mergency Response Phone <br />4. {Haste Tracking Number <br />WASTE MANIFEST CAL000348851 <br />1 <br />000-7411-7446 <br />5, Generator's Name and Mailing Address Generator's Site Address (if different than mailin <br />FLAG CITY CHEVRON <br />6421 CARTt7(_ AVE <br />L-001, CA 06242 OCT 18 2013 <br />Generator's Phone2- 09-481-8160 <br />fi. Transporter 1 Company Name U.S. Et1:l��lurpb <br />G�eHtt99E �iLT <br />SHOP HAI.ARDS SOLUTIONS, INC � <br />rAL _ <br />7.17ansporter 2 Company Namr,. U.S. EPA ID Number <br />B. Desklnated Fadlity Name and Site AddressU.S. EPA ID Number <br />GEM-RA•Nt"Mil) C+waRDOVA, U -C:. �.>��IaH!►I}i�4983 <br />'I'IHs1i VM TFI10I 1100K RD. <br />RANCHO CORDOVA, CJS 95.742 <br />Farilitys Phone: f�16 351-0 �— <br />ga. <br />9b. U,S. DOT Description (Including Proper Shipping Name, llazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unil <br />No. <br />Type <br />HM <br />and Parking Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. NON -HAZARDOUS WASTE SCUDS <br />2 <br />DM <br />765 <br />N <br />a, <br />SOIL CUTTINGS <br />w <br />z <br />2. <br />7 <br />3. ~ <br />v? <br />�'t�.p4n„ <br />13. Special Handling lnstntrlions and Additional lnformalfon1.'I;_;114> s": l`&�A� .d��•. -rTrti - <br />- Ti•v�.a� <br />PR # , MC# IT tIN�a ALL c�GIL. i„a,I? <br />` <br />14 GENERATOR'S CERTIFICATION: I cnrlify the materials desrribad above on tliis manifest are not subject to lerleral regulations for reporting proper • dis posal of Hazardous Waste. <br />Genar orVoll'eror's PrintedlTyped Name SlgnaAue Month Day Year <br />1011 <br />--j <br />15.n,14natinnal Shipments ff�1 EF fromUS, Poriofea lexit:._._�____..___ <br />t to U.S. <br />ImporN <br />F <br />L_ <br />Transporter signature (for exports only)-, Date leaving U.S.: <br />IX w <br />a <br />16. TransporterAclmowledgment of Recelpt of Materials <br />Transporter 1 P.ri�n+te'dlf'yped Name Signature Month Day Ye e <br />IoQJ ie�✓% <br />Transporter 2 PrintedlTyped Name Signature Month ay Ynar <br />17. Disrrepanry �I <br />❑ I_._J Full Rejection <br />17a. Discrepancy Indication Spats ❑ Gtuantiry �I Type IJ Residue Partlad Rejection <br />Manifest Reference Number: <br />17h. Alternate Facility (or Generator) L1.S. EPA Ib Number <br />a <br />V <br />LL <br />Facility's Phone: <br />Monrh Day Year <br />W <br />17r.. Signature Ill Alternate Facility (or Generator) <br />e^ <br />Q <br />� <br />T <br />rn <br />Uj <br />A <br />18. Dow nated Faciliiy Owner or Operator: Certification of rer ipt of materials Covered by the manifestexcept as noted in Ilei 17a — _ Month Day Ya <br />Signahue <br />1`7 Name <br />-,.. 1 <br />V DESIGNATED FACILITY TO GENERATOR <br />