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NON-HAZARDOUS '1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number 07010-305 <br /> WASTE MANIFEST NOT R EQUElm 1 -BOD424a= <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Mitzi 01 ProlAmb US c�a CR&tom:C !�ELT.-an 0.0 Vj CK"Ic of t`i,y <br /> G=Cupoaft DrUa.hV7j;*+a*,N ,s gin,CA <br /> Generalors Phone: 317-241-7041 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ana-dixr4 l--4dSf!Irm-am <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi at�aci�Name and Site Address U.S.EPA ID Number <br /> (;,2 <br /> 001 Bahr Read Requ.-c-1 <br /> Facility's Phone: Wrbuf ..CA 94W 926ASS4=0 <br /> .Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description o <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> cc <br /> MA P <br /> w <br /> z 2 <br /> w <br /> c7 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> .ter i gra tib MbX3 or vztv-rzo <br /> are uppmxlnnta. 24 t=Ur C=,OCTICY af.'Xbr(M)424-MOctmn <br /> R <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 classed,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intematicnal and national governmental regulations. <br /> Generators/Oiferors PrintedlTyped Name Signature Month Day Year <br /> M CM a t :mus-,t , � f-`'�t �� 7 9 �� <br /> F 15.InlenraCrorial Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> ac 16.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Prinled>Typad Name J Signature �' Month Day Year <br /> 63 <br /> z Transporter 2 Printed/Typed Name Signature) L Month Day Year <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection Ful Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> M <br /> U <br /> rai Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> zz <br /> 0 <br /> rn <br /> � 1t <br /> r18DignatedFacifity Owner or Operator.Certification of receipt of materials covered by the manifest except as noted In Item 17a <br /> lTyped Name f Signature f Month Day Year <br /> 169-BLC-05 111977(Rev.9/09) �� 1 TRANSPORTER#1 <br /> 1 <br />