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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2,Page 1 of 3.Emergency Response Phone A.Man Nest Tracking Number <br /> WASTE MANFEST C A z, 0 0 0 0 9 A 1, 9 9 , 0 0 4.4 4 0 0 7 5 JJ <br /> 5.Generators Nacre and Mailing Address Gene tors S8e Address(it different than mailing address) <br /> BROOKSIDE COUNTRY CLUB 3130 BROOKSIDE ROAD <br /> 8303 SA!NT ANDREWS DRIVE <br /> ST�CKTON CA 952191867 TOCKTON CA 95219 <br /> Generators hone. <br /> s.Transporter 1 Company Normo ?eq ee=9963 U.S.EPA ID Number <br /> a <br /> 7.Transporter 2 Company Name U.S.EPA ID Numtmr <br /> 8.Designated Facil ty Name and Site Address U.S.EPA ID Number <br /> Set, 1Tq <br /> 1630. <br /> w <br /> =acilit <br /> ga 9b_U.S.DOT Desk' (imdudmg Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM andPackin,Group(ifany)) it.Total 12 unit 13.Waste Codes <br /> No. Type Quantity Wt.Abt. <br /> 0 1' Ces obaSf%*6(o L111AI IMOS 13,UA/M't3'®b III <br /> DIMI <br /> w <br /> 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Infonet on <br /> WEAR PPE, ERG#171 PROFILE#37452 <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION:1 hereby declare that the contents of this correignment are fully and accurately described above by die proper shipping name,aixl are classified.packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable Inlernalionaland national govermnental regulations.if export shipment and I am the Primary <br /> Exporter,f cert fy that the contents of this consignment conform to the terms o;the attached EPA Acknowledgment of Consent. <br /> I certify that it*waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a small quantity generator)is true. <br /> GenefatorsJC4 ore PrinledfTyped Name Signa Month Day Year <br /> J '6.I lMlk'3f Ship ents �{ <br /> I ImporttoU.S. ❑Exportfromu Porldentryfexit: <br /> M Transporter signature(for exports son � Date leaving U.S.: �- --- — <br /> JX 17.TransporterAcknxwkdgmerd of Receipt of Materials <br /> W Transporter 1.uhrtec/T me Signalur Month Dap Ye <br /> 40 �A Z/ , <br /> Q Transporte Print"ITyped Name 'Signature <br /> month pay Y r <br /> a <br /> 18.Discrepancy 0 (— <br /> 18a.Discrepancy Incication Space Quantity ❑ L_ <br /> Type ❑Residue !Partial Rejection ❑Full Re)eclio n <br /> Manifest Reference Number. <br /> 18b.Alternate Factlit•(or Generator)c(tPawrWo$tr V r—ft#-{ V.S.EPA ID Number <br /> L) ZL{�p A la,►t►� Oh44 <br /> a y aver SeM s.w p'1(�p a (��.�g <br /> nW F kly 5 Phone: Il 001 N Y �.! t 3 ate!U .:1 <br /> LU 18c.Signalure of Alt(rnate Facikly(o,Generator) Month Day Year <br /> 4 <br /> Z <br /> r, 19.Haza"us Wast-Report Management Method Codes(i.e..codes for hazardous waste Ireatment,disposal,and recycling systems) <br /> IM 1. 2. 3. 4. <br /> 20.Designated Fapf_y tTaner or Operator:Cartilicalion c receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Pr ntedff ped Name7 Signew Month Day Year <br /> k�- 1--tg)—t//-::I I ----I 3 1r) L/),? <br /> EPA Form 87C0 22(Re r.3-05) Previous editions are obsol DESIGNOD FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 6'd £966-9ZV-60Z eaiaAI!S no-( eLZ:61 60 96 090 <br />