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Please print or tvoe. lF.orm desianed for use on elile 02 -pitch) WeWritgf.) <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 8700.22 (Rev. 3-05) Previous editions aria obsole(e, <br />500 m <br />DESIGNATED FACT)LITYTO GENERATOR <br />X d tt:00 9TOZ/6T/tO <br />UNIFORM HAZ41iDOUS <br />1. Generator ID Number . <br />2. Page 1 of <br />3, Emergency Response Phone <br />d Man teat racking Num7 <br />00144' �. 2 61 JJ K <br />WASTE MANIFEST <br />C 7 <br />j <br />D00.746.7 <br />5, Generator's Name and Malling Address Generator's Site.Addreas (9 different than malling address) <br />SYSTEM TRANSPORT, (TWO <br />707 E. ROTH RD, <br />FRENCH CAMP, CA, 85321 <br />Generator's phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SHOP HAZA.iDS SOLUTIONS CADDOO646491 <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />9..Das U:5_ EPA ID Number <br />? <br />rNFi� AfYC: C.OR{501� LLC. G . <br />11O5StnlF9TI^ ROCKRD. C�1D98f9t3P+� f r <br />RANCHO CORDOVA, CA 95742 <br />FacOltya Phone: 91 �-3t51 �09HE3 <br />ga <br />9b- U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contalnerg <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Typal <br />Hpd <br />and Packing Group (d any)) <br />Quantity <br />w6vul. <br />o <br />1- CSN-RCRA HAZARDOUS , TE SOLID, <br />9SQREIENTS. 01L �' DII=1tiEL <br />2 <br />DAN <br />1360 <br />P <br />2 3 <br />552 <br />W <br />2. <br />c� <br />i <br />GEM has the. <br />permit for, and will <br />-c <br />4. <br />14. Special Handling Instructions andAddltlonal Infonnedon <br />FROH .E -WI 1577 _ <br />,APPROPMATE PROTEC-AVE CLOTHNr <br />SEE ERG #171 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ilhareby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ardlere classified, packaged, <br />marked and tabeledlplecarded, and ere In all respects in properoondition for transport according to applicable international and national govommental regulations, If export shipment and Ism the Primary <br />Exporter, I certify that the contents of this consignment cordorm to the corms of the attached EPAAcknowledgant of Conant. <br />I certify that the waste minlmtzabon statement IdeAlfed In 40 CFR 262.27(x) (if I am a larp quanilty gen F (b) (if I am a small quantity geneMs true. <br />Ge era Ofl rs PAhted e m Sloriatu Month Day Year <br />10 107 <br />ll�- <br />16. Intamational Shipments <br />11 import to U.S. Export from U,S, Port of entry/exit <br />❑ <br />Transporter signature (for exports only), Date leaving U.S.: <br />W <br />17, Transporter Acknowledgment of Receipt of Materials <br />TranspaAer rintadlTyped Name Signature �- Man th Day Year <br />QTransporter <br />2 PrintedfTyped Name Signature Mont, Day Year <br />18. Discrepancy <br />ryry <br />16a. Discrepancy Indication Specs ❑ quantity ❑ Type ❑ Residue U Pahlsl Re)ediort Dull Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />r3 <br />ut. <br />Facility's Phone: <br />W <br />18a Signature of Alternate Facility (or Generator) <br />Month Day Year <br />4 <br />2 <br />19. Hazardous Waste Report Management Molhod Codes (i.a., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />z. <br />s, <br />4. <br />20. Designated Facility Owner or Operator, Cerlfication of recelpt of hazardous materials covered by the man if at exca s noted In Item 18a <br />P 'ntedrryped Name Sign r 1 M tr a Year <br />EPA Form 8700.22 (Rev. 3-05) Previous editions aria obsole(e, <br />500 m <br />DESIGNATED FACT)LITYTO GENERATOR <br />X d tt:00 9TOZ/6T/tO <br />