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13 Waste Codes <br />4 <br />U.S. EPA ID Number <br />I Month Day Year <br />I I <br />57/837-/ <br />Please print or type. <br /> <br />Form Approved. OMB No. 2050-0039 <br />DOABA Transportation Inc. <br />3511 Del Paso Rd. Ste 160, Sacramento, CA Lat. 38.0763710 N x Lon. -121.3798550 W Generator's Phone. 916-240-4110 - I Lodi, CA 95242 Transporter 1 Company Name <br />PARC Specialty Contractors <br />Transporter 2 Company Name <br />U.S. EPA ID Number Clean Earth Specialty Waste Solutions I MNS000110924 Designated Facility Name and Site Address <br />U.S. EPA ID Number GEM Rancho Cordova LLC <br />11855 White Rock Rd. - Rancho Cordova, CA 95742 <br />Facility's Phone: (916) 351-0980 <br />CA0980884183 <br />it. Total 12. Unit <br />Non-RCRA, Hazardous Waste, Soild (Soil, Oil) <br /> No. Type Quantity VitiVot <br />ZiaD P <br />3 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. .Manifest Tracking Number <br />5. Generator's Name and Mailing Address CAC003132448 1 (80,) ,v5-7761 I 014745982 FLE Generator's site Address (ir di erent than mailing address) <br />US. EPA ID Number <br />CAR000159665 <br />ga Pb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers and Packing Group (if any)) <br />DF <br /> <br />ce Lu <br />ce <br />a. <br />Transporter 1 Printed/Typid Name <br />MA/1 vil Ite. Cito 1,44 <br />Transporter 2 Printed/Typed Name <br />1 <br /> —7— <br />D. <br />7A- k / 77 1--A- A. 1 . :8. screpancy <br />18a. ascrepancy Indication Space El Quantity <br />17. Transporter Acknowledgment of Receipt of Materials <br />Carton: Wear Koper OSHA approved <br />PPE POIWORG# When hancg the materials on this <br />manifest <br />CHEILTREC 1-800-4244300 PARC Jobilf: 361136 GEN ERATOR'S/OFFEROR'S CERTIFICATION: <br />I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport acxrding 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) (if I am a large quantity generator) or (b) (if I am ntity generator) is true. Genera es/Offerors Printed/Typed Name <br />trtkei "rd, <br />international Shipments <br /> <br />Import to U.S. O Export from U.S. Transporter signature (for exports only): <br />14 Special Handling Instructions and Additional Information <br />1. SOil & Oil ( tX55 o/t) Pronle# 7 SI W311-00 <br />Signature <br /> <br />Month Day Year <br />I 13 Zi <br />Month Day Year <br />I 67 / o PO <br />Signature <br />))41 <br />Type <br />Residue El Partial Rejection <br />Full Rejection <br />Port of entry/exit: <br />Date leaving U.S <br />Nigh Year\ <br />18b Atemate Facility (or Generator) Manifest Reference Number. <br />C-) <br />u_ <br />7) 19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />1 <br />12 13 <br />I Printed/Typed Nai;70 kt‘ <br />20. Z:signated Facility Owner or Operator: Certifica ion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />4. <br />Signature <br />lvlontU,., Day Year <br />I I 06 I 30 I <br />L)ES NATED FACILITY TO EPA's e-MANIFEST SYSTEM