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Fk <br /> Please pant or type.(Form designed for use on elite(12-pitch)rewriter.) Form Approved.OMB No.A0-0039 <br /> UNIFORM HAZARDOUS 1.GenemtorlD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number G B F <br /> WASTE MANIFEST CA K3006930 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ASSOCIATED TRACTOR SERVICE,INC <br /> 1323 W CHARTER WAY <br /> STOCKTON,CA 95205 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SHOP HAZARDS SOLUTIONS,INC CAD000846497 <br /> 7.Tmnsporter 2 Company Name U.S.EPA ID Number <br /> y 8.Designated Facility Name and Site Address - - U.S.EPA ID Number <br /> 0 GEM-RANCHO CORDOVA,U-C. CApg@WN 183 <br /> 11556 WHTE ROCK RD. <br /> RANCHO CORDOVA,CA 95742 <br /> Facility's Phone: 016.351-0980 . <br /> 9a 9b.U.S.DOYDescdption(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 WtNol. <br /> X 1 HAZARDOUS WASTE SOLID,N.O.S.,D,NA3077,PGIII i OF Or 17 P D007 DOGS 172 <br /> o (LEAD,CHROMUM) 7� <br /> 9 / <br /> W 2 NON-RCRA HAZARDOUS WASTE LIQUID DM 165 G 223 343 <br /> 0 DIRT,OIL,GREASE 8 WATER <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and No,9aWformabon <br /> FILE r <br /> 9w1-PROGLASS BEADS WITH METALS,DW-PROFILE OGR32203-01.OILY SLUDGE <br /> APPROPRIATE PROTECTIVE CLOTHING <br /> SEE ERG*171 EMERGENCY CONTACT:TOM BENTZ <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 and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cer iy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cedfy that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(f I am a small quantity generator)is We. <br /> Genemtoes/Offergrs Printedrryped Name <br /> �Q .Sign L Mo D� � Year <br /> L A VOl 1/2 &V � f 'n <br /> —r 16.International Shipments <br /> F ❑Import to U.S. ❑Fxpon from U.S. Port of enhylez8: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdn yped Name Signature Mon D Year <br /> KTransporter 2 Pnnted/Typed Name Signature O� Ge& Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue 4 nial Ran e';�e ❑Full Refection <br /> Manifest Reference 9�. 'J4d—k0 <br /> l25� <br /> 18h.Alternate Facility(or Generator), <br /> LL Facility's Phone: tf <br /> w 18c.Signature ofAllernate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> c ,. (q( 2 3 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1a <br /> (lyped arae t Sigalur Ip( a <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITVTO GENERATOR <br />