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Please print or type.(Form designed for use on elite(1 2-pit, • Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST CAL000•tAii yl ( � n6475 <br /> G B F <br /> 5.Generators Name and Mailing Address Generators Site Address(i different than mailing address) <br /> GREEN VALLEY TRANSPORTATION CORP aDfaf t GI-WAY as <br /> P O. A 254 TRACY,CA 95304 <br /> VERPtAlJ6,CA 953&5 <br /> Generators Phone:80t}077 5991 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SHOP HAZARDS SGL111IONS,INC. CAOOfip84949! <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address GEM-RANGI If)CORDOVA LLC U.S.EPA ID Number <br /> 11665 W"If ROCK RD, CAP.N00984IR3 <br /> RANCHO CORDOVA,CA 95742 <br /> 91&35,-11980 <br /> Facility's Phone: <br /> ge, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) <br /> No. Type Quantity Wt.N01. <br /> 1. 'I OM 45 G 223 34'3 <br /> c AHSORBENTS.OUSLUD 1i <br /> ga <br /> z Z. <br /> w <br /> G7 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> PROFILE <br /> SEE ERG#111 <br /> EMERGENCY CONTACT' <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 intemationaland 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ff I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GenerztoeslOfferors Pdntedrfyped Name Signature Month Day Year <br /> =j 16.Internalwna Sh mensOF <br /> ❑Impod M U.S. ❑Export from U.S. Port of en <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdntedrf Name signature Month Day Year <br /> 11 <br /> Pr", <br /> Z Transporter 2 Pn ped Name Signa Month Day Year <br /> C <br /> H <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity j I <br /> dy ❑Type El El Rejection FUII Reaction <br /> Manifest Reference Number <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> FacilWs Phone. <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste heement,disposal,and recycling systems) <br /> Iy+a 1. 2. 3. Notice: State of California requires <br /> generator to photocopy and mail to DTSC <br /> 20.Designated Facility Domer or Operator.Certification of receipt of hazardous materials covered by the manifest except as road in Item 18a within 30 days: <br /> Pdntedrfyped Name Signature P.O. Box 400,Sacramento, CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> EXHIBIT <br /> , I I T <br /> X I GENERATOR'S INITIAL COPY <br />