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is rr~ , f�Jrci x.22 <br />tl\S <br />Pf4ase print or type. (Form designed for use on elite (12 -pitch) typewriter.) 9 QoaQG-0nd Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3105) Previous editions are obsolete. _ DESIG Jk FED FACILifY TO DESTINATION STATE (IF REQUIRED) <br />�6 x'10528.1055 <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tra0 0 2 4 ekin Number <br />2768 FL <br />WASTE MANIFEST <br />CAL000167732 <br />1 <br />-- <br />8004249300 <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Fedex Freight Fedex Freight West Inc <br />1805 Fast 23rd Street Suite 1 4520 South Highway 99 Frontage Road <br />Little Rock, AR 72206 Stockton, CA 95215 <br />Generator's Phone: 1-326-7249 <br />6. Transporter I Company ame U.S. EPA ID Number <br />General Environmental Management, Inc. CAD983649880 <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 />Rancho Cordova, CA 95742 <br />Fadlity'sPhone: 916,351 0980 CAD 980884183 <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 Patting Group (if any)) <br />Quantity <br />Wt.Nol. <br />1-Non-RCRA hazardous waste liquid (Latex) <br />O 1 <br />910 <br />ADM <br />P <br />Z <br />2. <br />w <br />c� <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />1) ( I x 10 ah,,Approval 4R27853 PRO #1779538530 <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 international 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 terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (ft 1 am a large quantity generator) or (b) (if I am a sm quantity generator) is true. <br />enerators! eroes PrintedlT Name gna oonth any^ ear <br />b�'il� r,Z <br />J <br />16. International Shipment <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />- <br />Transporter sinature for ex ods o Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Prin yped Name gnature cont egar <br />y <br />! s . <br />lDay <br />:� t� ► ! <br />QTransporter <br />2 Printed/Typed Name Signature ay Year <br />fx <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejecti n ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA 10 Number <br />V <br />.0 <br />Facifitys Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />4 <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />w <br />1 It -0 <br />� � I <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pd Name <br />i Signature /Month Day <br />/Y)ear <br />`` <br />® id.�t t�'Q41 V V <br />EPA Form 8700-22 (Rev. 3105) Previous editions are obsolete. _ DESIG Jk FED FACILifY TO DESTINATION STATE (IF REQUIRED) <br />�6 x'10528.1055 <br />