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7 <br /> Please print or type.(Form desi ned for use on elite(12-pitch)typewriter.) W2281876,01011 SC PPW 4/7/200 S.Q. (f� IP4 2050-0035 <br /> UNIFORM HAZARDOUS 1.Generator ID Number sponse Phare 4.Mardfest Tracking Number <br /> WASTE MANIFEST, C A 0 9 B 11.6 9 7 5 A (800}4 1s 000005695 I <br /> 5.Generator's Name and Ma81ng Address Generates Site Address(d different than mailing address) <br /> Stotd®n US®TMR3p Yard <br /> 1944 N.E!P1fVM OfIn 1932 N.EI Proal Odd <br /> Woftcv,CA95205 Stol:Idon,CA95205 <br /> Generator's Phone: (620 <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> Okul naftm IrMronmWal Son4w Im M A Q 0 3 9 3 2 2 2 0 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Cloon Hwbors San Jon 10218 Q <br /> CADQ594943L® <br /> R <br /> San lose,CA 05133 <br /> Fad' s Phone: <br /> 9a. 9b.U.S.DOT Description(indult Proper Shipping Name,Hazard pass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WWd. <br /> UNi999,WASTE FLAMMABLE LIQUIDS,TO)OC,N.03:, aoai <br /> ® x (METHYL CARBAMATE,PETROLEUM OISTILLATESX 3, 0 01 OF 00035 P go <br /> (6.1).PG u <br /> 2. UN2811,T ONC SOLIDS,ORGANIC,N.O.S., 392 <br /> K (METHYLCARBAMATE,BORIC ACIDX 6.1,PC II 001 OF 00090 P <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 2 <br /> 1.Lcow ERG#131 1XiS <br /> 2.zcmc ERG#154 1x30 <br /> 15, GENERATOR'S/OFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and aceuratety described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulallons.If export shipment and I am the Primary <br /> Exporter,I rectify that the contents of finis consignment conform to the term of the attached EPA An kmoMedgme nt of Count. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a SII quantity.~)is true. <br /> tors/Offeroes PrInted/Typed Name Signature Month Day Year <br /> 04116 109 <br /> J 16.International Shipments ❑Import to U.S. ❑Export from U.S. Pat of entry/exit <br /> Transporter signature(fa exports orgy): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ri Transporter 1 Printed/Typed Name Signa Month Day Year <br /> a 04 IVI CO <br /> ch EMAMnO Transporter 2 Pt ai OONAO1) <br /> yp <br /> TZ ed Name Signature Month Day Year <br /> fY <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Num <br /> 18b.Alternate Facility(a Generator) U.S.EPA ID Number <br /> V _ <br /> Facitys Plane: <br /> LO 18c.Signature ofAltemate Facility(a Generator) Montin Day Year <br /> Q <br /> 19.Hazardous Waste Report Managemernt Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj® ' H141 2 H141 - 3' 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintecirrIq <br /> Year <br /> ypedName Csilinature G2/� _8aI ( <br /> EPA Form 870012(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REOUIRED <br /> awn He rbors has the @Wqwme pml%for col 0543-0939,was"put is ship," <br />