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a <br /> W} 01711a19B <br /> NON-HAZARDOUS 1 Generalors US EPA ID No Mandesl Doc No 2 Page 1 <br /> WASTE MANIFEST a of <br /> 3 Generator's Name and!Jailing Address <br /> INXZRX CHEVERON LODI <br /> H1%TY 12 <br /> 4 Generators Phone( 209 ) 4 6 7- <br /> 5 Transporter 1 Company Name 6 US EPA ID Number A Transporier s Phone <br /> INVI 0 4 <br /> 340211 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number $ Transporters Phone <br /> 4� <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number C Facility s Phone <br /> INVIRO TEC n/a 434-0211 <br /> 2480 ATHENS AVE <br /> 4r LINO LN � <br /> 11 Waste Shipping Name and Description 12 Containers 13 14 <br /> Total Unit <br /> No Type Quantity WVVol r <br /> a non haz waste 11auid nos 001 t a <br /> waste water <br /> w S <br /> fl G b <br /> E S <br /> T N <br /> F R - <br /> A c <br /> T <br />'Y O r'S <br />`- R o- <br /> s Yl <br />[ d <br /> i <br /> I <br /> p.. <br /> }a <br />= r + D Addi coral Descnptrons for M2tcnals Listed Above E Har•dring Codes ter%Nnstes Listed Above <br />> T <br /> 11 purge water <br /> 15 Special hanCling Ins%Vions end Aodruoral In'orma,on <br /> emergency TROY 916-826-3803 y < <br /> i <br /> 16 GE14ERATOR S CERTIFICATION I cer^1 ite r-.L G�ne-ribed ebo%e o^ ^s mandEsi e net cublccl lo e-^er-1 reg iia re,=Icr re;)oring prcpe d aposal of Ha,acus lvasle <br /> f Pnr edT ped Na—Ie 5ignc'cr� 1sn9 ti nDR) }ear <br /> T t' Tianspo�er 1 Ackro,+Ieogernenl of Peccipt of va er aIs <br /> R <br /> A r-_P <br /> N f f Nam- Srgnaic 1 i� ✓cni i ocy rep <br /> 10 18 Transposer 2 AcKno++leeger-�ent of Receipt of I,Jale als <br /> R <br /> T Pnnled Typed Name Srgna'ure <br /> E mon h Day Year <br /> R <br /> 19 Discrepancy Inoicction Space <br /> F <br /> A <br /> C <br /> I <br /> L 20 Facilr y OK ner or Opera'or Cerid ca,on of receipt of t%esle materials cove,ed by This manifest except as poled n Item i 9 <br /> I <br /> P mled,T}ped Name Sign re MomA Day Year <br /> Printed by J J KELLER 8 ASSOCIATES INC <br /> Neenah W1 54957 0368 12-BLS-05 Rev 12/98 <br /> ORIGINAL -- RETURN TO GENERATOR <br />