Laserfiche WebLink
jNON-HAZARDOUS I Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST i I iW F U'GA&E' 153 l 91 <br /> 5 Generator's Name and Mailing Address Genetata's Site Address(d different than mailing address) <br /> 'A/0 <br /> ' Zoe yf 39v S"�r✓cr j' <br /> Generators Phone: <br /> 6.Transporter 1 Company Name f�1 U.S.EPA ID Number <br /> NOT APPLICABLE <br /> 7.Transporter 2 Company NameUS.EPA ID Number <br /> NOT APPLICABLE <br /> S.Designated Fw Ay Name and She Address US.EPA ID limber <br /> F?Ef'OLOGY NAY ROAD NOT APPLICABLE <br /> 6428 1W ROAD -`JACAVILLE, CA Q,5887 <br /> F3ci s Phwa <br /> 1 10.Containers <br /> 9.Waste Shipping Name and Description 11.Total 12.Unit <br /> No. Type Ouanfity Wt1Vol. <br /> 1. <br /> wz <br /> r= <br /> W <br /> 2. <br /> W <br /> 3. - — <br /> I <br /> i <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> ENVIRONMENTAL <br /> I <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> maAed and labeled'placarded,and are in all respects in proper condition for transport according to applicable international and nalional governmental regulations. <br /> Generafors101ferors Printed/Typed Name Signature ^- —"` ' Month Day Year <br /> 15.International Stupme6ts <br /> z ❑Import to U.S. ❑E pod fmm U.S. od of entryleft <br /> Transporter Signature toy exports o i Dale leaving U.S <br /> rs 16.Transporter Acknowledgment of Receipt of MateriaLv <br /> Transportor 1 PrintadlTyped Name Signature * Month Day Year <br /> a Transporter 2 Prinled/Typed Name Signature Month Day Year <br /> ¢ <br /> 1•- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indcafion Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection i <br /> Manifest Reference Number. <br /> H 17b.Alternate Facifily(or Generator) U.S.EPA ID Number i <br /> U <br /> ua- Facility's Phone: <br /> 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 0 <br /> w <br /> ' I <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Ilem 17a <br /> Pnnted/Typed Name _ - Signature MonVI,.- Day_ Year <br /> 169-BLS-C 5 11979 'Rev. 09) DESIGNATED FACILITY'S COPY <br />