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r <br /> f <br /> Please print or type. Form Approved.OMB_No.2050-00333 <br /> 1-Generator ID Number <br /> UNIFORM HAZARDOUS 2 Papa 1 of 3.Emergency Response Phone 4.Manifest Tracking Number '�� ! <br /> WASTE MANIFEST CAI 000 1 4 N + i gyp)4,'4 . �h 120382 / ;' u J <br /> 5-Generator's Name and Malting Address Generators Site Address(0 different than malling address) eN <br /> FHiI tlChtVtigAf{IS <br /> _e307 ! 1{ylVFI�"Flt)t:SCAL 1.114 CA <br /> �VGenerators Phone: 209 838-8150 <br /> 6.Transporter 1 Company Name --- <br /> wrinr U.S.EPA ID Number <br /> flvll FNVIROI+IIVtENIALSEfMC:F'• <br /> 7:Transporter 2 Company Name U.S.EPA 10 Number <br /> YlrOfttOWIDF R>"CC.)VFftY 'rYg1EM tNt. <br /> B.Designated Factlity Name and Site Address US EPA IDNumber <br /> YF13 MANAGI-MfNT INC <br /> 6ryp(}U`,I4lG#1WAY 945 <br /> (OMA <br /> Fac (s Phone; <br /> ga. 9b.U.S.DOT Dradpticn(including Proper Shipping Name,Hazard Class.ID Number, 10.ConLwws <br /> HM and Ping Group(t any)) 11 Total 17.UTO <br /> No Type Quantity WtNd 13 Waste Codes <br /> t r, RCRA t-lA7AR00IJ!5 WASTE SOLI[)f(3if Y '34A 11),;: <br /> 4 { <br /> to <br /> r <br /> LU <br /> I <br /> 3 - - <br /> 4. <br /> 14.5pecl d Handling Instructions and Add clonal Information ---- <br /> tMEfiGF14(.r 1 k 41 ACI - HkMJREC 1-80(144,0--jo w,jr.w I f i{ty, I14A1 4i RE:�i, . nA. t•„r �-�____; <br /> 16262314RSIPH16I1 OILY S()LIG OEBR1S ;APf'Nt3 RiAIF f'YE t t)t11PMFNI � <br /> I <br /> 15, GENEmarked and tab 10FFEROk'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the proper shippingname,and are cl dieyj, �" <br /> marked and Iabeledlplacaroted,and ere in an <br /> respects in proper Corndltlon fa transport aaord! to Ifexp Prinuu eu, w <br /> Exporter.I eeelily that the contents of this consignment conform to the terms of the ateched EPA viowfe ble rntef Cons and national grlwrmxrwntal regulations.If export shilxnent and I am Ube Primary <br /> Acknowledgment of Consent <br /> I cerlNy that the wade mininkatan statement Identified In 40 CFR 262.27{a){if I am a large quantity generator)or(b)(if I am a srrwM"itity grxru(alor)is Ire. <br /> Generator`Wffemes Printedffyped Name Signature <br /> Month Day Year I <br /> 1b.International Shipments <br /> � Import to 1' ❑Export from U.5 Port of entry'ua1i <br /> Transporter signature(for exports only): <br /> Date leaving u S <br /> W 17.TransporterAdtn*dgrnent of Receipt Qf MaterialsLU <br /> — — -- <br /> C TransPongr 1 _Wyped Name Sgnature -Af"�� - <br /> �� Month^' Day Year <br /> Transporter 2 PrinlwVTyped Mpff* Signature i r I <br /> MonthDay Year <br /> 18 Disaepancy -. <br /> 18a.Dkcrepaney Indication space ❑ 4uanttyT <br /> ❑ ype <br /> ❑Residue ❑Partial Rejection El <br /> l Full ReleclKxm ` <br /> � 18b.Alternate Faality•ar Generator) Mandest Reference Nuntrm <br /> U.S.PEA ID Number <br /> U <br /> 4' Facility.Phone' € <br /> W 18c,Signature of Alternate Faclffly{or Generator; Mash Day veer I <br /> �r �—_ <br /> W19 Hazardous Waste Report Management Method Codes Q•e.,codes for hazardous waste treatment,disposal,and recycling systernsl - — 1_ <br /> 0 1 2. <br /> T. <br /> a ---- - - - <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous rnateriats covered by themarmilest except as noted in Item 1&, <br /> .rted/rypedNeme Signature 3 <br /> Mamlh Day I Year <br /> EPA Form 870D-22{Rev.12-171 Previous editions are obsofele � _ i.__ <br />