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Please print or type.(Fo11n designed for use on elite(12-Pilch)typewriter.) <br /> 1.Generator ID Numeer Foy Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page I o1 3.Emergency Response Perone d.Man sl Tmcking Nu r <br /> WASTE MANIFEST... ,. ,.CAW00091172...- . . - . , .. 916371$747. 0036 1 048 JJK <br /> 5.Gedep(o[a rr MahiDpAddLess Generators SBemaress(a sherent Nan mailing address) <br /> 11530 WREE3GHiLEM6E ROAD.. <br /> STOCKTON,CA 95419 <br /> Genem m's Phone. 409360-1041 <br /> 6...... nen 1 Company Name' U.S.EPA ID Number <br /> RVI <br /> .,.AAMOS MWONMENTAL SECES;:WC.,. .. . . ... . . CAUD44003M <br /> 7.Transporter 2 Company Name <br /> U.S.EPA IO Number <br /> 9. Y ;010: US.EPA ID Number <br /> . ; ... <br /> =5I OLDSKYLddE'RW10,.. - - CA70006MIl <br /> 1fEITlL•F1At0 CRY:CA 93439:. ' <br /> .. . .. .. . <br /> Facli sPhone: 80P442.2M.. <br /> 9a. gb.U.S.DOT Description(irnduding Proper Shippag Name,Hazard Class,Charter. 10.Cordium s 11.Tod 12.Unit <br /> HM and Pact"Gmup(dany)) No Type OrMnBN TMNd 13.YVAO Codes <br /> pPADS) <br /> � I <br /> W <br /> W 2 <br /> 3. <br /> p 4 <br /> 5 . <br /> tor. 9�1)aCRF361V1_a d 'grlgl to li .BE-40 HOUR TRAD&D AND USE APP MMM PPE <br /> aaq 3, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hembydedare that ere contents of this consignment are MIN and accurately described above by the tamper shipping name,and ere classified,packaged, <br /> marked and labeled/placarded,and am in all respects in proper condition for thmsp rid according to applicable international and national timmmenlaa regulations.It export shipment and I am Me Primary <br /> Export,I candy that the contends of this cotmgnment onto"M the <br /> Iamni of V*enriched EPAAdmow/edgment of Consent. <br /> I ce"Mal the waste minimtraUon statement idanBed in 40 CFR 262.27(a)(If I am a large quantity generator)a(b)(if I am a small quantity generator)is true. <br /> (s/Offerors Print O a ign nae Month Dry Yaw <br /> r � 3 ro bs <br /> 16.Inmmatiaal Shi ends ❑Impa1 m U.S. <br /> Transporter signati m(for e ❑F Item U.S. Pan e rn exit <br /> exports only): Dete lleaving U.S.: <br /> K 17.TmmponerAdmDMedgmentaf Raceidol Mabdala <br /> Tmnspowner 1 PMredRyp Name SgnaNre • _ Monts Day Year <br /> S v <br /> 2 Transponer 2 PdntedRyped Name Signature 9 Month Day Year <br /> C <br /> r <br /> i18.Discrepancy <br /> 18a.Discrapenry Indication Space ❑ Dconth, ❑Type ❑Residue ❑Pa tut gmidd ar ❑Ful Rejection <br /> IBB.Alternate Facil y(a Gornmi a) Manikin Reference N.W r <br /> J U.S.EPA ID Number <br /> U <br /> LL Facility.Phone: <br /> Maj 18c.Signature ofAltemate FadN(or Generator) Month Day Year <br /> w19.N ou s sport Management Method Codes t.e.,codes for hazardous waste meatmnt,disposal,and recycling systems) <br /> 1 20.Designsid FrOmtion of race othmrd%s materials covemd by th antes xce noted in Item 182 <br /> P' am <br /> big-PTA Form 84OM22(Re. Previous editions Tmobsolete. D (GNAT D FACILITY TO DESTINATION STA (IF hEQUIRED) <br /> 10299.1148 <br />