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N0N4IA2ARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Respanas Phone4.Wuta Tracldrg N bar <br /> WASTE MANIFEST 1 600 183-3716 1 70/J <br /> 5.Generators Name and Mailing Address Geneabys SHa Atklress('rf d�6erem than ma9ig address) <br /> ('A W TTY rARRIFRS T!C'A7435 IAT:37.71921209 tow:-121.5362629 <br /> 102 PICK=RING WAY SUITE 10 TRACY CA,95377 <br /> EXTON PA 19141 <br /> Generator a Pw*. 613369.7260 <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> PATRIOTmmoNMENTALsERYE33 I Dtwsde66794 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> c1epm ijm7fokc, 6M0I120✓1fr"eNTAt— S�I'L✓Io= /v� os�32z <br /> 6.U�fgutmd FacN1y Name am Site Address <br /> U.S.EPA mbe, <br /> If FAN NARER55AN Y11'aF I!C <br /> 1021BERRYESSA ROAD CAD059494310 . <br /> SAN X)SE CA 05133 <br /> Fath 's Prone 406-441-0962 <br /> 9.Wasle Stripping Name and Descnptbn 10.Canta'a9re 11.Tata) 12.Unit <br /> No. Type Quantity Wi <br /> NON DOT REgRATtX),14ATOM MDM*,(MIR 01ORCaA W <br /> SOMS)'NON HAMM= 01 OF 55 <br /> G <br /> i� '�.' 2. NON DOT REGUTAT®MATERIAL MDCRAIE,(OTHER INORGAW -cv <br /> . ; 501-SDS),NON HA7ARDOIb 01 OF 55 G <br /> A. 4 <br /> 1S,Special Handing Instructions and Addlbnel Impnnation ' <br /> WEAR PAOPER PPE 3)CHUM14 2)C11337495 QC EVENT"2435 <br /> '7117dr7l4Ryl Ptl l701g169Y/ <br /> Sc PP6J 11411Z,917 <br /> 14.GENERATOR'SIOFFEROR S CERTFICATION.I hereby declare that the tomenta of this Wnelgnment are htty and=urataty,described above by the proper shipping name,and are classified,packaged <br /> marked and labeled/placanded,and are In al respects h proper condition for transport according to appicabie international and national <br /> gwemmenlel repuletbre.GerstratoeslOffierteI, <br /> s Primed7ypetl Name signature Month Day Year <br /> S r„ r I 6e-1- <br /> r 15.International Shipmentff <br /> ❑Importb U.S. ❑Erporifmm U.S. Potof entryletil: <br /> _ Transporter Signatum(for aaports oriy): _ Date leavtnt U 5' <br /> C� 16.Trarspo4er Afi Wedgoent of Receipt of Materiels <br /> Transporter I Pdnfedrtyped Name 4 Signature Month Day <br /> Day Year <br /> ai Transports SWAIU ' I"Month�/ Day I Y Y <br /> 17.Discrepancy <br /> 17a.Diecrepervy aldicallon Space Ik[, <br /> ❑openly ❑Type ❑Residue ❑Pa tat Rejection ❑Full R.). 11 Ij <br /> Manifest Relererrre Number: <br /> e. 17b.Arernale Fadkly(or Generator) U.S.EPA Ip Number <br /> .I <br /> Facility's Phone: <br /> 17C.Signature of Artemate Facility(or Genarata) Montt Day Year, <br /> e. <br /> 2' <br /> e: y� <br /> � �. N � ✓� s4 � F+� 'ti��4 . g,�'�F�� k �'�°""���' '�"�.���k5+. tA'�14y }v ,�. `S V; <br /> ,y'� �"pct 4x"G .'§e:� k`-U v`v�. .:%�`,.T. +� ^`Zdx�}S��x •vj � y � r r���''{�•�^�•��.ax �,�z .�' ��.rk <br /> .ti <br /> 18.Das algid Facllty Onner or Opsmlon Certification o1 receipt m mmedels mvered by the manilr6t except as noted em 17a <br /> Pr:.rt R Name Signature -- M� 7� <br /> r i / <br /> 16E-81-C-0 5 11977(Rev.9/09) DESIGN#4D FACILITY TO GENERATOF' <br />