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'e Plpasp nrint nr Noe. (Form desioned for use on elite 112-oitdtl tvoewriter.l Tsr- 01()21- CJ9`J9 1o1®Sr;-9nt Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 10568.0460 DESIGNATED FACqLrrYlrO DESTINATION STATE (IF REWIRED) UNIFORM HAZARDOUS i. Generator tD Number " " 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number G B F WASTEMANIFEST CAL000167732 1 800-424-9300 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Fedex Freight Fedex Freight West Inc 1805 East 23rd street suite 1 4520 South Highway 99 Frontage Road Little Rooth, AR 72206 Stockton, CA 95225 Generatoes Phone: 6. Transporter 1 Company Name U.S. EPA ID Number General Environmental Management, Inc. CAD983649880 7 -Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number bMi Rancho Cordova, LLC 11855 White Rock Rodd Rancho Cordova, CA 9S742 FacifitysPhone: 916 351 0980 CAD980884183 ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard pass, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No, Type HM and Packing Group (if any)) Quantity Wt.Nol. ON1263 Waste Paint related material, 3, III 0 X 333 DM Ul% D G z 2. w c9 3. 4. 14. Special Handling Instructions and Additional Information 1H / x ) Approval OR27033 ERG: 128 PRO #1569870282 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, marked and labeledfplacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (WI am a small quantity ge erator) is true. Generator'sfOfieroes Printed7TypedNam J Sig Month Day Ye J � 16. International Shipm is ❑ Import to U.S. ❑ Export from U.S. if Port ofentry/exit: LC Transporter signature (for exports only): Date leaving U.S.: W IT Transporter Acknowledgment of Receipt of Materials Q n iter i Printedlfyped me Signa Month Day Yle �G/ ,t �% U G spo r 2 Pnnted/Typed Name Sr atureMonth Day Year r 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Altemate Facility (or Generator) U.S. EPA ID Number J_ V , Facilitys Phone: w 1 8c.Signature of Altemate Facility (or Generator) Month Day Year z H19. Hazardous Waste eport Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C 1. ,� 2. T- 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest exAept as noted in Item I Sa ed Name f Signatur Month Day Year g0% -V L )A /j/ I 1�Z EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 10568.0460 DESIGNATED FACqLrrYlrO DESTINATION STATE (IF REWIRED)