|
04/02/2019 04:54 FAX
<br />Please prinl ort . (Form designed for use on elite 12410h) typewriter,)
<br />FWA5TE
<br />HAZARDOUS 1• Generatorl0 Number Flae 1 of 3. EmergeMANIFEST AffL74
<br />s Name and Mailing Address Generator's
<br />SYSTEM TRANSPORT. (TWT)
<br />707 E_ ROTH ISD.
<br />FRENCH CAMP, GA 95321
<br />Generator's Phone:200•90 `
<br />6. Tramporler 1 Corlipany Name
<br />SHOP HAZARDS SOLU11ON6,1K
<br />Z; TranWrlur 2 Company Name
<br />DesfgaeledFacil4LWme and She Address.
<br />1 GEMlO i;t,RpgVA. LLC.
<br />11"'55 W" TE ROCK RQ.
<br />RANCHO CORDOVA, CA 95742
<br />FaaFl0ftne; �1t�351-Q�3
<br />ga 9b. U.S. DOT Descdptlon (including Proper Shipping Name, Hazard Class, ID Numbor,
<br />HIM and Picking Group (if any))
<br />I. N("RCRA HAZARMILIS WASTE SOLID
<br />0°� ABFORBENTS: OIL S IXSEL
<br />ht&I
<br />•
<br />Y
<br />.•, coni
<br />i
<br />JIJ�
<br />I
<br />2 7 20'3
<br />Form Approved. OMB No. 2054-0039
<br />y Rsan-
<br />eumber
<br />rj
<br />-74dG HEALTH D ) 4 512 G B F
<br />Ile Address (If dltiereri than mailing address)
<br />" �
<br />1
<br />EPA 10 Nuinoo'
<br />C. 6497
<br />U,S, EPA ID Number
<br />f
<br />L
<br />U.S. EPA ID.Number
<br />-
<br />CAD68OW4163
<br />10. Containers
<br />11,'total 12. Unit
<br />13. weals Codes
<br />No.
<br />Type
<br />Qupnilly
<br />Wtivol.
<br />shipping.
<br />DM
<br />795
<br />1 P
<br />1223
<br />I d52
<br />i
<br />it .�,. ,.,, �.. ;: c .y ', .... i• f.; 1
<br />20r0r*F icrlily.Owjiui er4po�06r: Certification of'receipl dharardgus'materials,cmiered by the'msnifesI exeapt.es noted in jloa'18a,.
<br />ed/Typed Name �', _ gnature Month •'Qa
<br />y Year,
<br />Ai
<br />tt
<br />EPA Form 870X22 (R6. 3-05) Previous editions are obsolete. Y l
<br />GENERATOR
<br />DESIGNATED FACILITY TO GENER' V
<br />„ ' .
<br />GEM has the appropriate
<br />permits for, and will accept
<br />the waste this, generator is
<br />shipping.
<br />f.
<br />14, Special Handling Instrucllons andAdditional Information
<br />PIWAilt— AGR
<br />APPROPRlATt=�� CTIVE C.LOTHNG
<br />SEE ERG #171
<br />5. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contorts of this eonbignmena4e fully and accurately described above by the proper shipping name, and are classified, packaged,
<br />marked and labeledloacarded, and are in all respects in proper condition for frarspol according to apps cable international and national governmental regulations, If export shipment and I am the Pftary
<br />j
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br />I Certify that tho Waste minlmizalion statement identified in 40 CFR 262.27(a). (If I am a large quantity generate(if I em a smell quantity genereror) true.
<br />GegetofQg
<br />Sgne
<br />:Day ' Yae f
<br />�r 1
<br />F
<br />WIMmadorAl h pmAnts t'� "'
<br />Jptport fo US. t—PExporilrom lf.S., k • Pon
<br />>; . •'°
<br />^' ,' ...
<br />alit D'
<br />De161sadinUS'
<br />g
<br />is •4•`.. r
<br />�
<br />'(7 Tr�dglfortCrACknpwje nenlofReeelliLofMaterials r �
<br />��. �r,r,.. •,
<br />,'�
<br />Tranapo r 1 P" dffY t 519rlalura
<br />Month ' Dayr7 , Y9er
<br />r.
<br />.
<br />C
<br />Tianspbrtifr 2 Print LTy d Name Si alure
<br />Month Day Year
<br />0[
<br />-
<br />18. Discrepancy
<br />163. Discrepancy Indication Space ❑ Quantity I,._.I Type ❑ Residue ❑ Partial Rejection
<br />U Full Rejection
<br />18b, Alternate Facility (or Generator) U.S. EPA ID Number
<br />j
<br />:Facdity'a'Phone:
<br />18c.
<br />Sigbature of Alternate Facility (or Generator) _.
<br />htontn Day Year
<br />H rdoll$YvastD fteptre,MorwgomentMelhotl CodfgSjrp,; cddms.fpr hazy sous waste traalmani, disposal, and recycling systema)
<br />2:, 14.
<br />it .�,. ,.,, �.. ;: c .y ', .... i• f.; 1
<br />20r0r*F icrlily.Owjiui er4po�06r: Certification of'receipl dharardgus'materials,cmiered by the'msnifesI exeapt.es noted in jloa'18a,.
<br />ed/Typed Name �', _ gnature Month •'Qa
<br />y Year,
<br />Ai
<br />tt
<br />EPA Form 870X22 (R6. 3-05) Previous editions are obsolete. Y l
<br />GENERATOR
<br />DESIGNATED FACILITY TO GENER' V
<br />„ ' .
<br />
|