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Please print or tone. (Form deslaned for use on Mile 119-nitrhl ivnmvJmr 1 <br />• - mrnnn ray Year <br />- - <br />UNIFORM NAZgRDOUS 1, Generator ID Number 2. Pagel Emergency Response Phone <br />norm Approved. UMU Nn. 2050-0038 <br />4, Manifest Tracking Number <br />WASTE MANIFESt C',4t,f/002"1604 1 fip0•.9"R-.`5231 <br />g9 <br />11 �i� Jai <br />5. Generator's Name and Mailing Address Generators Sils Address if different than mailing address) <br />i'e I'R( 51 fiiV ll'l„�,f,11119 CSt <br />2.902 Lalciiele 1�4r” 11i�1 Ir <br />baa. � <br />r,l <br />Generators Phone: sj aWat1 NVig..9431 P175.159 ( 8RF Cfr?c".1:1C11F, !'./A. a,�.r Iii? <br />0. Transporter 1 Company Name <br />U.S. EPA ID Number <br />Wold EltvixnnmeTdi Eftatpy; P r f, flrn ?,s%, TA'ect SaW amentfz, CA 4,4t>01 <br />7 Transporter 2 Company Nama <br /><',41:0g0037?,& # <br />U.S. EPA ID Number <br />S. EPA ID Number-- <br />h9 UM4 $1 ) flya-'y% r}7 <br />Faclliys Phone: 707`451 3276 bxlas;rfa 1d1 ,> CA 0 0 <br />C.4i)48204247_1 <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hal Class, ID Number, 10. Cordo em <br />HM and Packing Group (if any)) <br />it. Total 12. Unit <br />13. Waste Codes <br />No. Type <br />Greatly Wt.NoL <br />L <br />Etd,1, NA2212,:ASIiMWS,9;PG111 <br />151E <br />P <br />z. <br />{ <br />^- <br />4. <br />14. Special Handling instructions andAddiOonel Information <br />Satf Frabtr4soo, CA 44109, (415) 771-6600. AsNbi Removal RerlttiTemer tft <br />41)(TR61, Magged, sealed, lffjWed). <br />15. GENERATORS/OFFEROR'S CERTIFICATION: Ihereby dedmis that the contents of this consignment are mf' is eceurately descI! laim by <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to <br />the proper shipping name, and are classified, packaged, <br />(. <br />applicable international and national governmental <br />A' ,.lyeporter, I certify that the col of ibis consignment conform to the terms of the attached EPA Acknowledgment Consent, <br />regulations. if expert shipment and I am the Primary <br />of <br />reall that the waste miNmiiation statement identified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if i am a small quantity generator) is hue. <br />GeneradeslGgerors Pdnte ffivoed Name <br />i6. Inlemaiional Shipments <br />❑ Import to U.S. ❑ Export from U.S, Pod of erdwent: <br />Transporter signature (for exports only) _ Date leaving U.S.: <br />H17. TranspoA�erAcknoMedgmenfof Receipt of Materials <br />F <br />18. Discrepancy <br />iOs. Discrepancy Indica( on Space ❑ Quantity ❑ <br />Type ❑Residue ❑Partial Rejection <br />Manifest Reference Nmnber. <br />Full <br />18b. Altemaie Facility (or Generator) U.S. EPA ID Number <br />U <br />FaPhone: <br />low 180. Signature ofAltemate Facility (or Generator) At <br />19. Hazardous Waste Report Management Method Codes (le., codes fa hazardous waste treatment, disposal, and recycling systems) <br />2. 31 4 <br />20.13aslgnated acORy Oumeror gperalor. Certification of receipt oihazardeus materials covered by the manifest excaplas noted in Item 18a <br />PrintedrrypedN mg., m. <br />Signature Mc <br />o <br />EPA Form 871 (Rev. 3-05) Previous a ikons are obsolete, <br />1)r,IGNFi'i'RnD FACILITY C <br />Rejection <br />