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• i <br /> NON-HAZARDOUS 1.Generafor ID Number 2 Page 1 of 3r Emergency Response Phone �r �Waste Tracking Number <br /> i, WASTE MANIFEST. . . # '� 1' � b..1 R.=.s} f"i p <br /> f <br /> ' 5.Generator's Name and Mailing Address, `,«fraRr'1 } Generator's Site Address(if,ditlereni than mailing address) . <br /> CAI.TRaNS'01�TMICTh'O #1 A, 0115TRi T#'115 rJGt INTEAMice <br /> ` .,'+ttiEr�r�1 11 1 riti:kk� ,X4111 1� 0.10440UTtHR . <br /> �RFSNO CA Q3720 CA <br /> Generator's Phone: ArVA 4 A.,fa i,°. "' •-' _ <br /> 8.Transporter 1,Compeny Name n �, U.S,EPA ID Number " . _ ; j <br /> q i <br /> 4ar4�1"I�tt/!t=`CK't3i�Vi14T`A:9..� i�if wV��6�f.�.: ;i� ,�`. t� a E} � •� :� '1 .. <br /> 7.,Trar(spoder 2 Company Name r-UZEP/l_ <br /> D <br /> ber. <br /> INum t <br /> 8.Designated Facility Name and Site Address " U,S.EPA ID.Number <br /> t'omr_RO1'.1111 1}+1'11.)1+0.1. n <br /> cullsum c;rr CA 94686 <br /> Facile 's Phone: •, »n <br /> i ,u r r, , 15516 ` 0 4 10:Containers fl.`total <br /> 12.Unit <br /> 9.Waste Shipping Name and Description., quant fly WLNol.: <br /> No: Type <br /> cc 1,PKA 1 HAZARDOUS VA;S SOUDS C-2,01tA*ATI <br /> W 2 k 1: <br /> cs <br /> 13,Special Handling Instructions and Additional Information' 9 <br /> t <br /> ! WEh tk1 t1?i +tl87w L" + rsi�'s'a l.:' t 'ft�E' ►x� f�". V tl T' <br /> to • 4'.1'1 t.k � a `Z l+Fit' a `; E�tTui k�I'+;" <br /> , 1dF�E1 �nCfw1 1:"�4"2.R� ��i.ZhPT' �'#ir'�•iY"'��.r 4.:_.» +r <br /> o. <br /> t 14,GENERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare tha411te oontenlsof this consignment are fully and accurately desodbed above 6y the proper shipping name,and are classified,.f iackaged n ) <br /> markedand labeled/placerded,and are in all respects io proper condition for transport according to applicable inlematonal and natlana governmental regulations <br /> SI nature *" ,»— .. Month °' 'Yr. P _ <br /> GeneralorsrOfferoes Printedffyped Name i <br /> V y} i.. >. {l{ / / •; /:tr 3 r <br /> 1S.international Shipments V Import ` ~ 1rorU S`.4.;1p Pod of enlry/exit _ $ <br /> ElsloilS. > ? ti . <br /> Transporter Signature for ex oris on r^ ' °. ' Date leavin US 3 <br /> ir Lu 16.Transporter Acknowledgment of ReF elpt of Materialyea <br /> s 1 , *f vt ` <br /> :. + „ Signalurer f Month Day r Ye <br /> t �• Transposer 1 Psntedrryped Name . <br /> CL <br /> } < Transposer 7PrrnTeillryped NameSignature ar <br /> Month- Day Ye <br /> cc <br /> 17.Discrepancy } < r{�l-� l <br /> t 17a.Discrepancy Indication Space �7 LJ Residue Pasial'Refectiom IJ FuQ F1ejeGon !. <br /> f. L1 Quantity _ . ©TYPa <br /> Manifest deference Number. <br /> } 17b.Alternate Facility(or Generator). U.S:EPA 10IJuinber <br /> U <br /> Facilit's Phone: <br /> {,. Y - Mohlh Day Year' <br /> w 17c.Signature of Alternate Facility(or Generator) <br /> , L <br /> a <br /> 1; 18.Designated Facility Owner or Operator:Certification of <br /> receipt of materials covered,by the manifest except as no in Item 17a y <br /> Printed(fyped Nama ayp} <br /> �''" ( Signature Mdri / Y ' <br /> TF}INSP0�3TR 2. <br /> f 169-BLCGO 6 10498(Rev.9/09) E <br />