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L <br /> f 'p FormA roved.OMB No.2050-0039 <br /> Please print or type.(Poon dealgned forum on elite(12-pitch) ter.) PP <br /> 1.Generator ID Number ' ?.Pag�i of 3.Emergency Response Phone t Man I r Ing um <br /> UNIFORM MANIFESTS - . m. 014445713 f Jv <br /> WASTE MANIFEST L � Q fl is �' y! `r�,! � , 1-npU-4�:�-t'Lp: N 1� <br /> 5.General Name and Mailing Address Aft Sharryn PloU{fe GBneretd's She Address(If different then ailing address) <br /> i3aFevr,` ; !n: Sai Fuel!?%-ICI: <br /> 5918$[orreridpe hl all Road4t[ri Sharon Flouffe F.+425 t';"pacifrc?vz' <br /> Pleasanton CA 446@8 Stoektsr,, CA 95207 <br /> Generators Phone' .9 7 " , F f <br /> e. ransporty I pehy Nem; U.S.EPA ID Number <br /> E-mranrnantal LOWShe-, Ina Cr F: 0 0 t� i 7, ` 1 -_ <br /> 7.Transporter 2 Company Name U.S. A ID Number <br /> e.Dealgneted Faa4ly ame and She Address U.S.EPA ID Number <br /> Hazrnacln;. ' <br /> 'If StaDium Dr <br /> arlsas City PAG e4 129 <br /> Faa4tys Phone: 816 9245884 P.l G G u 2 1 1 2 3 <br /> ga, 9b.U.S.DOT Description imcudng Proper Shipping Name,Hazard Class,ID Number, 10_Containers 11,Total 12.Unit <br /> HM and Padding Group(If any)) No. Type Qua" WINol. 13.Waste Codes <br /> OK 1Uh11U93,'AASTE F(arnrnab!e ltauids.n.o.s Jp2selinel3 P311 >, 1" C�C)1E <br /> o X. - <br /> z 2. <br /> LLI <br /> 3. <br /> 4. <br /> 14,$paUal Handling Instructionsand Additional information: 1110-1,E't Ab=orbent,33sokie&GNkef 44ES-6:742 <br /> 5 5 <br /> 18. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the convents of this consignment ere fully and accurately described above by the proper shipping name,ard are classified,packaged, <br /> marked and labeledlplacerded,mid are in all respects in proper condition for transport according to applicable international and national governmental regulators If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAotmowledgirent of C t. <br /> . J cordy that ft waste minimization statement Identified In 40 CFR 252.27(e)m I am a large quantity generator)or(b)(el a small uam8y generator)is true. <br /> GenerehrralOEerals Nn*ffyped Name ' <br /> Signature y Year <br /> .International shipments ❑Inglortto U.S. Ll Export from U.S. Portofenby/exit <br /> Transporter signature(for exporls ermty): Over lecNng U.S.: <br /> pec 17.Transporter Acknowledgment of Receipt Of Materials <br /> mss. T porter 1 Printedrtyped Hl�e - r aqua r _ MIft Day Year <br /> }$�i �( <br /> � f1 � 3 is <br /> pZTransporter 2 Pr"rryped Name Signaeaa Mondor Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Reiecdon ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.ARemate Facility(or Generators U.S.EPA ID Number <br /> J <br /> U <br /> LL FacRys Phone: <br /> w 18c.Signature ofAtterrum Facility(a Generator) Moth Day Year <br /> 2 <br /> Go 19.Hazardous Waste Report Management Method Codes(Le.,codes far hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4, <br /> 20.Desgnalea Facility Owner or Operator:Certification of receipt ofhazardous materials covered by the manliest excapzas noted In Ilam 18a <br /> come �-^ ('-1 naWre ey <br /> II \ J <br /> EPA Fo 870 Rev.3-05) Previous editions are obsolete. - `[SESIGNATED FACILITY TO GENERATOR <br />