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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I-GeneratorlD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 2 8 0 7 6 8 1 1-8004249900 013482539 JJ K <br /> 5.Generators Name and Maili Address Att Sharon Plauffe Generators Silo Address lif different than mauling address) <br /> Sa4eway nc. Safeway Fuel#2707 <br /> 5918 nIeridae Mail Road;Attn:Sharon Plouffe 6426 N Pacittc.Ave. <br /> Pleasanton CA fl4$88 Stockt Dn CA 95207 <br /> Genelaio s;PWn <br /> B.Transpoder l Company Name LLS.EPA ID Number <br /> Environmental Logistics. Ina CA R 0 0 0 2 1 7 5 1 3 <br /> 7.Transporter 2 Company Name U.S.E AID Number <br /> esignated picidlyllama and Site Address U.S.EPA ID Number <br /> Crosby&Overton <br /> 1830:W. 17th SYraei. . . <br /> Long Peach CA 80818 <br /> Fa sPhpnd. 582: 432.5445 C A.0 fl : d 0 1 <br /> ga 96 U.S DDT DesxvipSanpnclumrgPrapat SNppvg game,HeiaN Class,IDlumber. FCcntav�w� <br /> tt.Torai�. tz Unn 13.ymsly Codes <br /> HM ant PaikulA GrouP(if any)) - Quantity'.! WINol,ION1993NASTEFlarwable llquid5,n.q.s..(gasoliholl,"011 17001 0018 134 1 G <br /> 2. <br /> 3 : <br /> '.� 111 9. 4 .tU..OT�i <br /> 4. <br /> ENVIRONMENTAL.HE LTH <br /> 14.Spoelal Handplg lnsiruchphSfind AddfUanal bdormaon �}(I ) G#128 INV:*10880744 <br /> j'k5 <br /> -ti GFNERATORSJOFFERDITS CERTIFICATION: I hereby declare Netthecpdod,ofWe consignment are rNfy and aecoately descrlbEd aboveby(he proper shipp'ug namBra,`d.and cNssZ84;P.gdkaged, <br /> marked.and lethipbodVacarded,and are b elf JeWeels In proper.sand litch fork ansf cri a*Adlrg to epplicgi International and ralionat governmental regulators,if export shipment and I am ft Primary <br /> Evader,I cedlfy thatthe isealants d this densloNtOnt conforMAD b terms Ofthe attached EFAAariowledgment of Consent <br /> Icerhy Ihatlhewasle minimization Stateplontifentlfed in 40 OR 28227(aj(if air a Urge gllanity gen ndpr)or{6 (Nlzm uyiUry 9Cnarmor)to Stye:: <br /> GenwatoeslOffa sPn.A yplon <br /> ed NaMe �y : SIg� ' w m Dzy Yost <br /> )c r <br /> 10intonbAW`All ghlpmeres f—I <br /> rw ��. '. I_.,a lmpadto tlS � ❑E�oY from'U.S. Part ofenhyleAp. <br /> $. Transporter siadAbue(foexpdde obi _bate leaving UAS <br /> ce 17.YrenapoNa.AcFmowtedgmentofRewlplplMafed"aIS <br /> Tranaporter'1 Piinted/ryped Nadre $IBnaWre - Monty Day Year <br /> � � SA4 kc.`2 Q / <br /> Transponof2 FrintecuTyped Name Signalure omh ey ear <br /> 18.Qlearopancy'. <br /> 18a.Disaepahcy lndtcalbnSpace I1 oueunty D1ypa - ❑Residue Partial Rejection ❑Fuh'.R .Won <br /> Manlrest Reference Numbor <br /> : 18b.A11ematefaellity(or GOW8100 - U.S,EPA ID Number <br /> V ' <br /> u'Q.. Fachtys Phone: <br /> W ,I8c.SydafuraofAJlemate Facitty(or Generator) - - Month Day Year <br /> a <br /> a. <br /> 19.HazardousWa Repal,M- =ant Method Codes(Le,,codes for hazateous waste treatment,disposal,and moyding systems) <br /> 20.Designated Faddy Owner jr Opertor CedlAcation ofrecelpt qj anitest except as noted In Ite5 1 B <br /> Pnnterinype ' arae p9nalure A nth at year <br /> EPA Form 87g022(Rev.3-0 PrelvMAecridol teoBsolete. DESIGNATED FACILITY TO PESTINATIOAI.STATE(IF.RE AED) <br />