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Q <br /> k•/type. orm designed for use on elite(12-pitch} <br /> N•HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> ASTE MANIFEST CJOW1571019 I 1 1 2w- 944-%2i ! <br /> S.Generator's Name and Mailing Address Generator's Site Address(if different than mailing aarMqr <br /> INTERSTATE TRUCK CENTER 0"NAVY t <br /> 8TOCKTOK CA 95206 MCM14,CA 0,5206 <br /> Generators Phone: <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> 8"KAZAMS sot-u-noNs'1w <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 1V)I..IA E-6I`I~-�f�1C�4k.,801-11 OHMS,LL( <br /> 5130 Vtf..EFrE1R 1 ST Ads 131 t" <br /> PHOENIX..Z 96W3 <br /> Facility's Phone: 602-2U-205 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Glass,ID Number, 14.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.N01. <br /> 1. ("VERSALMSTE ALKALINE BATTERIES I DF P <br /> BATTEFOES,DRY,#dc3 cWT R&A-ILATED <br /> :f f,,-r i go <br /> fir , <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> PF.OFILE#'2W <br /> 14. GENERATOR'S CERTIFICATION: I certify the matedais described above on this manifest are not subject to federal regulation8 aor re peY'disposal of Hazardous Waste. <br /> Generatars101jorCr?s Pri yped Name Signature . ' Month Day Year <br /> 15.lute tion ip E •' <br /> Import to U.S." ❑Export from U.S. Port of enirylexiC <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter rrntedfryped Na Signature Month Day Year <br /> ' $ <br /> Trans 2 rrimtedfTypeclOName Sign MoTith Day ear <br /> 17.Discrepancy <br /> 17a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 171b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> 17c.Signature of Alternate Facility{or Generator) Month Day Year <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in item 17a <br /> Printedrryped Name Signature Month Day Year <br /> M-C-C-11 <br /> 6-GENERATOR'S INITIAL COPY <br />