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Please nrint or tvne. (Fnrm dpsinnprl for imp nn plitp (19_nitchl tvnpwritpr) 111111111 IN II I Fnrm Ar, my d r)AAP Nn )nFr)_nnio <br />crH norm z5ruyr22 ev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number772. <br />Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />4;`:i�0, :s-., 74 <br />i <br />f�c 7Pti � <br />008680277 FLE <br />5 Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />i-1 ! 'F'h L. ...�_r't a'I i'Ctf: i.a ",.ij1'!:.' 2�07r0 <br />.'•.`Li.� r'`.JHL <br />Generators Phone: q , v r =`fd CA 1 c—t T.11r s; t <br />6. 1 ransporter I Company Name U.S EPA ID Number <br />P, i'>r .^i:'_ -,-3Ni '°•� W,4 t°P -I its 3 C1 r-, Irt�l 0 1 ,i - q 4 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site AddressGenetal En V I r0 n gt i Mgt, LLQ; U.S EPA ID Number <br />1855 White Rack Road <br />Rancho Cordova, CA 9574tT <br />Facili s Phone: 1:4 1 <br />9a, <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 (if any)) <br />Quantity <br />Wtivol. <br />0 <br />1 on RCRA hazardous waste, liquid (Consumer <br />1 <br />4F <br />115 <br />.3 <br />,131. <br />w <br />rPiof� RuRA I azardais= waste, solid (uansumer <br />1 <br />OF <br />00081 <br />A <br />331 <br />Products) s <br />3. <br />4- <br />14. Special Handling Instructions and Additional Information 1, 110524(Non-RCRR Liquid Waste (CA Only) - Lousepack) 2, <br />1111529(NDn RCRA Solid Waste (CA Only) - Laosepack) <br />15. GENERATO/CSKIFFEROR's CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping, name, and are classfied, 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 t am the Primacy <br />Expoft, tartihy Ihal the omtents of conalg w*N ea*m b ltie tams of the afticintd EPAAcknowledgment of Consent. <br />' ' <br />I ow* the waste m Idef&W in 40 CFR 262.27(a) (N I em a large quantity generaM or (b) (ff f am a small quan ' genes rj h <br />a YPMPY/ <br />Tom'; .. <br />%v( <br />� <br />/ l t i <br />-i <br />1p. tWwAiFonal ShIprnents <br />ort of entrplexit::Transporter <br />❑ Import to U.S. ❑ ExportUS. Vate <br />signature (for exwrts only): " leaving 47 <br />17. Transporter Acknowledgment of Receipt of Materials f �! <br />Transporter i. PnnteaFyped Name Month Day Year <br />Mt)�J <br />a <br />,Anthony .,hack / Lf � fQf � 32 <br />fiEr- PM!iewrgNedName .. - - ... SignatureMMIM Day YW <br />18, Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full R*dion <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL <br />Facility's Phone: I <br />W <br />18c. Signature ofAltemate Facility (or Generator) <br />a <br />Month Day YBer <br />z <br />u19. <br />f <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />—I <br />� <br />1 <br />rI2 U / Ll� �3 4. <br />LI <br />i <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br />166 <br />nnte&Typed Name Signature Mont Day Year <br />r k I k &tn e2 C Rd I nn, . �L�,� ..., 1 11 I n l 1 1 -21 <br />crH norm z5ruyr22 ev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />