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�G�2 8�2Ot C� <br /> NON44AZARDOus 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST C A R 0 0 0 1 2 3 4 5 5 1 1-800-424-9300 WR2598-001 <br /> 5.Generato(s Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> Chevron 90557 <br /> PO Box 6004 - Chevron EMC Waste Desk 139 SO CENTER <br /> San Ramon, CA 94583 Stockton, CA 95202 <br /> GenerawsPhone: 877 386-6044 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> VE a L_�A- 6cA+t-4 Nc.4- 456 oi- <br /> 7. nsporter2Canparty s / Z-l� �� E Numbera­ <br /> 6.6slgnated Facility Name and Site Address U.S.EPA Io Number <br /> Veolia ES Technical Solutions, LLC <br /> 1704 West 1st Street <br /> Azusa, CA 91702 C A D 0 0 8 3 0 2 9 0 3 <br /> Face- `s Phone: 626-334-5117 <br /> 9.Waste Shaping Name and Description <br /> 10.Containers 11.Total 12.Unit <br /> No. Type Quantity W1Nol. <br /> Ir 1'NON—DOT REGULATED MATERIAL (Construction, ' P <br /> Demolition Debris and Soil, Non—Regulated). DZ` <br /> Z 2 ' 1 <br /> c� <br /> 3. <br /> 4- <br /> 13.Special Handling lnslructlonsand AddilionallNonnation Wear Level "D" PPE, gloves, goggles, tjpin�h <br /> I. Profile# 615562 protection (if liquids present) <br /> WR2598 ( ERG: NA <br /> SO # 0015155919 <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 /> madred and labeledlptacarded,and are in all respects in pmpar condition for transport according to appllcab!e tamational and national governmental regulations. <br /> GeneratafslOfferors PrintedlTyped NainiO� ^^/g tura �C a Q� Manth Day Year <br /> it �L�Jt �1` a+4 d <br /> ILI <br /> 15.International Shipments ❑Im rt tc U.S. ElPo Export from Port of en lexit: <br /> Transporter Si nature for rts on' Date leaving U.S.: <br /> cc 16.Transporter AcfzwvAedgment d Receipt of Materials <br /> 9 Transport 1 Pnntedrfyped Name ignat Month Day Year <br /> y <br /> 10 1-.2-0114 <br /> a Transporter2 ruyetlfiyped me Month Day Y <br /> F Ii\�(7�j�' 1� } <br /> 17.Discrepancy <br /> 17a Discrepancy indintion Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> ?- 17b.ARemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> !uFadlys Phone: <br /> 17c.Signature of Allemate FadCty(or Generator) Month Day Year <br /> a <br /> z <br /> w <br /> 0 <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noAn 101 17a <br /> PrinledlTyped Name signal Month Day Year <br /> Zoo <br /> 169•BLC-06 10498(Rev. /09) DESIGNATED FACILITY TO G ENt RAT R <br />