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Please print or type.(Form designed for use on elite(12-pith)typewriter.) Form Approved.OME1 No.20500039 <br /> P UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST C A I, 0 0 0 0 9 9 9 9 n t 100444 ,9075 JJ <br /> 5.Generator's Narre and Mailing Address Genet tors Site Address lit different than mailing ad1dress) <br /> PROOKSIDE COUNTRY CLUB 3930 BROOKSIDE ROAD <br /> 11603SA'NTANDREWS DRIVE <br /> Generators hone: <br /> �:T(, 14 CA 952191867 TOCI(TON CA 95219 <br /> 6.Transperter 1 Company Name U.S.EPA ID Number <br /> 7.Transpdxler 2 Cmapany Name U.S.EPA ID umber <br /> 8.Designated Faeil ty Name and Site Address U.S.EPA ID Number <br /> Soe. �Yq <br /> Faciti! <br /> ga, 9b.U.S.DOT Descripli (Waludi g Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1 t.Tola[ 12 Unit 13.Waste Codes <br /> HM and Parkin;Group(H any)) <br /> t No. Type Quart ify WLIVot. <br /> O 9. frofA�rNS't11b�R. �.�4lrll �u�'1�p{�+��1��Q16►iE, � <br /> 31 <br /> 00 <br /> z. <br /> G <br /> ru <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional informal on <br /> WEAR PPE, ERG#171 PROFILE#37452 <br /> 15, GERERATOR'SIOFFEROR'S CERTIFICATION: f hereby declare that the contents of this consignment are tullyand accurately described above by the propw shipping name,and are classified,packagpd, <br /> marked and Iabeledfplacarded,and are in art respects in proper condition for IranspoRaccording to applicable inte nal[onaland national governmental regulations.H export shipment and I am the Primary <br /> Exporter,I cert fy that the contents of Utisconsignment conform to the temrsof the attached EPAAck owledgment of Consent. <br /> I certdy[hal the waste minimization statement identified in 40 CFR 262.27(a)(if Ian)a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generaloes,f011 torr PrinlonadfTyped Name SigMonth Day Year <br /> r ,.,- 6�� 17-1 <br /> '6.t Irnaeauee Ship nts t _�1 <br /> 1. J Import to U.S. ❑Export from U Port of enhyfexit: <br /> Transporter signature(for exports only): _ <br /> Dale leaving U.S.: <br /> w 17.TransporterAcka)wledgment of Receipt of Ma(erials <br /> Transporter 1, rintet7T me SigItu Month Day <br /> 1AJ1 A^' f? Y.. <br /> CTransporter f PrinteclTyped Name S[gnature Month Day Y r <br /> 1e.Discrepawayy '1 <br /> 18a.Discrepancy Incicalion Space <br /> Quantify ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reterenoe Number: <br /> 18b.Alternate Facilit•(or Generator)C.10le" r Vt 6N.M.,iy1 U.S.EPA ID Number <br /> W Faclkty'sPhone: 3g{�tlSP/h S.i 011 Z� Alv1J t 36$ 14IS <br /> w 16c.Signalure of Aha mate FaclGty(or Generator) Month Day Year <br /> 4 <br /> 2 <br /> -,a 19.HazarWus Waste Report Management Method Codes(ie.,codes for hazardous waste troatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> i <br /> 2U.Designated Facif.y Owner or Operator:Certification c receipt of hazardous materials covered by the manifesl except as noted in Item Ilia <br /> Printed'T ped Name kf L Signatur w, Month Day Year <br /> jL <br /> EPA Form 87CO-22(Re 1.3-05) Previous editions are obs- DESIGN D FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 6'd E966-8LV-60Z 8Jl8AliS nod 869:11, 60 96 oaQ <br />