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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M020445098 <br /> an�ife�syt Tracking Number{� Q I�( <br /> WASTE MANIFEST CARQQ024I49 1 916.371-'6747 Q 2® `t 5 V 9 V J V" <br /> 5,Generator's Name and Mailing Address Generators Site Address(if different than mailing address} <br /> P.O. Il E RGAfiAPO 238196 N HWY 9.4 M04A6E Ga (-F) FF <br /> ACA a,CA 95220 aCWv4PO,CA 95= <br /> Generatrir"sPhetlil ' B$�927$ Aitr i c4 11nine} <br /> 6.Transporter 1 Company Name U.S.EPA ID Num <br /> RAMOS ENVIRONMENTAL SER%ACES INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Num eh, <br /> 8.Designated Facility Name and Site Address RHOS ENVIRONMENTAL SERVICES INC. U S.EPA ID Number <br /> 1615 SOUTH RIVER RD. CADD44DO3556 <br /> WEST SACRAMENTO,CA 95691 <br /> Facility's Phone:91E'371-5747 <br /> ga, 9b-U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WINol. 13.Waste Codes <br /> w 1. NON RCRA HAZARDOUS WAS 11l S40W (CAL, DEBT . h_ P sr_ <br /> 00S <br /> w 2. <br /> 3. <br /> d <br /> '14.Special Handling Instructions and Additional Information <br /> 9191-1 PROFILEV E,RGM71 j <br /> E.R. CONTRACTOR: RAMOS ENVIRONMENTAL <br /> HANDLERS SHOULD IE TRAINED AND USE APPROVED PPE <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurateky described above by the proper shipping name,and are classified,packaged. <br /> marked and iabeledlplacarded,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)(if I am a large quantity generator)or(b)jif I am a small quantity generator)is true. <br /> Gener I esJOfferor's PontedfTyped Name Signature Month Day Year <br /> CU s 1 <br /> j 16,Internatlonal Shipments <br /> j.._ ❑Import to U.S. ❑Expott from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> I-- Transporter i PrintedlTyped Name Signature Month Day Year <br /> O 1 <br /> aZa Transporter 2 PrintecirTyped Name Signature Month Day Year <br /> c� <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityElT e ❑Residue Partial Rejection <br /> Type El ❑Full Rejection <br /> Manifest Reference Number, <br /> F 18h.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> u- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> r— <br /> Q <br /> 2 <br /> y19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1. 2. 3. 4. <br /> r, <br /> 20.Designated FaclI4 Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncled in Item 18a <br /> Printed{ryped Name Signature Month Day !Year <br /> -' i <br /> EPA Form 8700-22(Rev.12-17) reviouseditions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />