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D : 1C 0! `t39. L0! 7 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />EPA Form 8700-22 (Rev. 3-b5) Previous editions are obsolete. <br />10777.0244 DE TED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />Vuu rwNiwcu. Umo INV. cuoU-vuoa <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trecking Number <br />WASTE MANIFEST C&OMN51 1 IND -748-740154637 G B F <br />5. Generators Name and Mailing Address p q Generators SileAddress (if different than mailing address) <br />8421 CAPITOL A , -, <br />LODI, CA 95242;-,. <br />Generators Phone.0"81-81130. <br />6. Transporter 1 Company Name S�I�� soiuTloNs, INC U.S. EPA ID Number <br />CA0000646497 <br />7. Transporter 2 Company. Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address, GEMA COPAWA, LLC: - U.S. EPA ID Number <br />11 fi.55 WMTE: RFK 1�: , ..::.::.. CAD9 193 <br />RANM CORDOVA .CA 95742..: <br />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containe s <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />13. Waste Codes <br />No. <br />T e <br />a. <br />(MONE.GASOLINE) (D018), ;,..,>, : .' <br />i ur <br />307. <br />0018% 352 <br />0 <br />w <br />z <br />2. <br />w <br />3. <br />4. <br />1a. i "�' cid :b I PUMP FILTERS. HOSES &.DEBRIS_>1. <br />APPROPRIATE PROTECTIVE CLOTHNG <br />SEE ERG #171 .... r <br />15. GEN ERATOR'51OFFEROR'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 EPAAcknowledgment of Consent. <br />certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Printed/Typed Name Signature Month Day Year <br />VUOfferors <br />J <br />zImport <br />. Int m tions S ip en ' <br />LJ to U.S. ❑ Export from U.S. Port of entrylex t: <br />- <br />Transporter signature (for exports only): Date leaving US.., <br />S.:17. <br />- <br />17.Transporter Acknowledgment of Receipt of Materials <br />TransporterP'tedrryped Name Signature Month Day Year <br />0 <br />O <br />CL <br />CAI <br />QTransporter <br />2 Printed/Typed Name Sig atur Month Day Year <br />H <br />1R ni-ronnnry <br />18a. Discrepancy Indication Space El Quantity El Type ❑Residue ❑Partial Rejection ❑ FUII Rejection <br />r <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J <br />v <br />LL <br />Facililys Phone: <br />W <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LM <br />1. <br />J� <br />� <br />t 1 <br />2. <br />1 <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the m fest except noted i m 18a <br />Printed/T ed Name S ture Month Day Year <br />w Lt Ibl:�Vrn-'Ito <br />EPA Form 8700-22 (Rev. 3-b5) Previous editions are obsolete. <br />10777.0244 DE TED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />