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Please print or type. Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID NunOer 2.Page 1 of 3,Emergency Response Phone 4.Manifell Tracking Number - <br /> WASTE MANIFEST C&000348756 I 2011.833.8711 001984947 G B F <br /> 5.Generators Name and Mailing Address 7-ELEVEN STORE#39208 Generators Site Address(if different than mailing address) <br /> 4888 SALIDA BLVD. 25460 S SCHULTE RD. <br /> Generebrs Phoria:208.833.8711 <br /> SALJDA.CA 95388 TRACY,CA 95377 <br /> . <br /> 6.Transporter 1 Company Nemo SHOP HAZARDS SOLUTIONS,INC u.s.EPA ID Number CA0000646497 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> GEM-RANCHO CORDOVA,LLC. woe000aeaw <br /> 11855 WHITE ROCK RD. ., <br /> RANCHO CORDOVA.CA 95742 <br /> Facilitys Phone: 916.351-0980 <br /> 9a. 9h.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Canter ners11.Total 12.Unit 13.Waste Codes <br /> -HM and Packing Group if any)) No. Type Quantity M.Nol. <br /> A t. � �jCRAt1�17, QQU3YV.ASTE SOLID 2 DM �JP 352 <br /> of aultBEtJ I a 6 uEaEL FUELS 'J <br /> z z. <br /> W <br /> RJ <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PRORLE#446437-02 <br /> SEE ERG 9171 <br /> 15. GENERATOR'SfOFFEROKSCERTIFICATION: I hereby declare that he coments of this consignment are hdy and accurately described above by he proper shipping name,and are dasstfied,packaged, <br /> marked and labeled/placarded,and are In all respects in proper ocr idon for transport according to applicable unemotional 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 tenns of the attached EPAAdmoviledgment of Conssi <br /> I certiy that the waste minimieaticn statement identified in 40 CFR 262.27(a)(it I am a large quantity generate)or(b)(if I am a small quantity generator)is <br /> Genretor Olfamrs Pdn yped Name Signatu - 1 Monro Day Year <br /> 4--1 <br /> F 16.In motionalShip nts ❑Import to U.S. ❑Eqw from U.S. Pod o exit <br /> = Transporter signature(far exports only): Data leaving U.S.: <br /> W 17.TransporterAdmowledgment of Receipt of Materials <br /> Transporter s PnnteM Name Signature Month Day Year <br /> �- Z 1 <br /> QRyped <br /> Transporter 2 PrintedName Signature Month Day ear <br /> K <br /> 19.Discrepancy <br /> 1Ba.Discrepancy Indication Space ❑ Quantity ❑Type ❑Pzrtiat Re ❑Ful Rejection <br /> Residua lection <br /> Manifest Reference Number: <br /> 13b.Alternate Facility(or Generator) U.S.EPA ID Number - <br /> 7 <br /> U <br /> a Facilitys Phone: <br /> a Iso.Signature ofAllemate Facility(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste resonant disposal,and reading systems) <br /> C 1. � - 2. 7. 4. <br /> 20.Designated Facility Owners Operator.CeruAcadon of receipt of hazardous materials covered by me manifest except as noted in Item 189 <br /> 1 Pdintype a Sgna Monro Day Year <br /> 091 115 <br /> EPA Form 8700-22(Rev.305) Previous editions are obsolete. - <br /> 11449.0205 DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />