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woo fr <br /> NON-HAZARDOUS 1.Generator ID Number `- 2.P*i of 3.Ennergkicy Response Phone 4.Wasix,Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 2 6 1 9 6 3 1 8001 424-9300 CHMW <br /> 5.Gq lois Generators Site Address(it different the mailing address)'001 <br /> 107 VAL DEMANMgMT IONS INC PKWY <br /> ti <br /> STOCC TOrr CA 962D6 <br /> Generatces,Phone: 209 982-0422 <br /> 6.Transporter I Company Name U.S-EPA ID Number <br /> FREMOLM ENVIRONMENTAL SERVICES INC C A R 0 0 0 1 7 1 0 1 7 <br /> 7.Transporter 2 Company Name U.S.EPA ID Nurriber <br /> S,Iyaft b nWeAddress US.EPA 10 Number <br /> 0 _% <br /> HWY 96 11 M11 6 OF:CY 16 ACRES <br /> BEATTY NV 89DW <br /> Facilil('s.Phone: R6 W3-220.3 N V "1 3 3 0 0 1 0 0 0 0 <br /> 9.Waste Shipping Name and Description .10.Containers 11.Total 12.Unit <br /> No. Type Quantity MjVol. <br /> 77, NMPiAZARDOUS WAS1 E,SOLID(SAND BLAST' 1= ) <br /> J. <br /> 2. <br /> 3. <br /> 4 <br /> Meda IF AMWM PVVIdW RX AWQVaI <br /> 14.GENEFtATOR'SIOFFIEROR'S.QERTIFICA71ON: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 /> marked and labeled1placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator'F s Printedrrypod YaRe Signature f Month Day Year <br /> 15.Internatonall ShipmemM Import to A FJ E.Pw f.U.S. Port of trylwd: <br /> Transporter S'nature(for exports only): Date leaving U.S.: <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> dSignature i nied(Typed Name I Sl Month Day Year <br /> Transports <br /> T L 1.,-P, o <br /> z Transporter 2 Prinle*7y*Name Signature Month Day Year <br /> I17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Q..Mjty El Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number; - <br /> 17b.Ansimate Facility(Dr Generator) U.S.EPA 10 Number <br /> UFacHity's Phone: <br /> ; <br /> 10 17c,Signature of Afternate Facility(or Generator) Month Day Year <br /> W <br /> !4 <br /> z <br /> o <br /> 15,Designated Facility Owner or Operator.Cartilicartlon of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pdntedffy*Name Signature Month Day Year <br /> 169-OLC-0 5 11977(Rev.9109) GENERATOR'S/SHIPPER'S INITIAL COPY <br />