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DTSC- OG -1900. 0692 <br />1`r I$7931-204 <br />Finesse print nr tuna IFrum desinnedfar use on elite 112-oitchl ivoewriter.l (� i ., Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) PreVous editions are obsolete. /OESIGNATEDfAGM TO DESTINATION STATE (IF REQUIRED] <br />10502.0196 <br />UNIFORM HAZARDOUS v <br />1. Generator ID Number <br />CAL000167732 <br />age <br />L <br />Icy Response Phone <br />800-424-9300 <br />4. Manifest Tracking Number <br />1002042715 FLE <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />Fedex Freight Fedex Freight West Inc <br />1805 East 23rd Street Suite 1 4520 South Highway 99 Frontage Road <br />Little Rack ,S R3 a Stockton, CA 95215 <br />Generators Phone: 49 <br />6. Transporter i Company Name U.S. EPA ID Number <br />General snvironmental Management, Inc. CAD993649880 <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 <br />11855 White Rock Road <br />honeCord e� e�, 3% ()-9828CAD980884183 <br />FRey's <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (d any)) <br />Quantity <br />WINOL <br />I.Fdon-RCHN MarMus wase liquid (Latex) <br />® <br />291 <br />0 <br />DM <br />G <br />z <br />2. <br />w <br />t9 <br />3. <br />4. <br />KS 1W+pwna and Additional Information <br />�andling <br />1)( x rV ) Approval #R27853 PRD #1772370762 <br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby dare 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 acceding to applicable international and national govemmental regulations. It 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) (d I am a large quantity generator) or (bLm am a small quantity gen ) i e. <br />nerato s Pyintedrryped Name Signa Month LVy Year <br />1710 <br />–1 <br />F <br />16. In tuonai Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />= <br />Transporter ' nature for exports o Date leavi U.S.: <br />CC <br />17. Transporter Acknowledgment of Receipt of Materials — <br />—ear <br />t- <br />X <br />CL <br />Transporter 1 Pdnt d Name f ngna ay <br />' �f- .2. 17 0`� <br />a01ut 4 i <br />CAP <br />Transporter 2 Printedrryped Name Signature month Day Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Fact' s Phone: <br />WC' <br />Signature ofAltemate facility (or Generator) Month Day Year <br />Q <br />Z <br />H19. <br />H o Waste Re Management Method Codes (i.e., codes for hazardous waste treatment, disposal, <br />and recycling systems) <br />C <br />1.2. <br />3. <br />: <br />4. <br />1 <br />20. 252rted Facility Owner or Operate. Certification of receipt of hazardous materials covered by the manifest except a m I <br />Pdnte Name Signature Month Dam Yea <br />Vf, �bJ <br />EPA Form 8700-22 (Rev. 3-05) PreVous editions are obsolete. /OESIGNATEDfAGM TO DESTINATION STATE (IF REQUIRED] <br />10502.0196 <br />