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T r /V)1: 7 P. -1 -) Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Forrn Approved. OMB No. 2050-0039 4 GENERATOR 1. i UNIFORM HAZARDOUS WASTE MANIFEST 1, Generator .ID Number CACOil2 7ni BPI 2. Page 1 of 3. Emergency Response Phone c73_, greaCtts.Site 4. Manifest Tracking Number 0 0 5 5 4 6 8 6 1 FLE Generators Name and Mailing Address Address (if different than mailing address) 9/07 so 9/AiS, GLOBAL SEVEN OCEANIC _ A -8899444)Mili--Beof 19.5723 G1//,...bm.1/ e‘,..'a s'e-iveaiv, .7.531Y HOLT, CA 95219 Generators Phone: 2u 65-9551 1 Mar A h-z/9 i Transporter 1 Company Name U.S. EPA ID Number SHOP HAZARDS SOLUTIONS, INC I CADOOD1346497 Transporter 2 Company Name U.S. EPA ID Number I Designated Facility Name and Site Address GEM-RANCHO CORDOVA, U.S. EPA ID Number LLC. 11E155 WHITE ROCK RD. . CAD980684163 RANCHO CORDOVA, CA 95742 Facilitys Phone: 916-351-0980 I ga. 9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes 1. NON-RCRA HAZARDOUS WASTE SOLJD DIRT 8 OIL 1 DF 650 P 223 352 2 Special Handling Instructions and Additional Information PRORLE#GR29971-02 SEE ERG #171 . EMell-A/6.1 (1.67,diri--- A115- (1 )11-71,0 GENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the contents of this consi§nment are fully and accurately described above by the proper shipping name, and are classified, packaged, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if lam a large quantity generator) or (b) (ill am a small quantity generator) is true. Generators/Offerors Phnted/Typed Name Signature Month Day Year rit-- 6,41R_O_ I. . ic, 0 3 1 1-1- 1 . International hipments ."0"...... -J F- z — Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only) Date-leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed5d Name Signature x Month Day Year 01'2,-3 qonth Transporter 2 Printed/Typed Name Signe Day Year I I I I -4--- DESIGNATED FACILITY. ---0- Discrepancy Discrepancy Indication Space LII Quantity Type Residue Partial Rejection Full Rejection Manifest Reference Number: ' Altemate Facility (or Generator) U.S. EPA ID Number Facilitys Phone: I Signature of Alternate Facility (or Generator) Month Day Year I I I 19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1.414 I 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P(te yperif Iltirrwit\c" cA506....11(w) Sig . re 1 will.A. ii. Month Day VI I. iii. 'al Year 1 rd- EPA Fdrrs 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) 11250 1551