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Y w <br /> �Q <br /> C) <br /> NIVERSAL ENVIRONMENTALi o <br /> P.O.BOX 996, BENICIA,CA 94510,(707)747-6699 <br /> NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> f <br /> f V <br /> GEN€RATER <br /> Generator Name � etrtta . x Generating Location' fir- <br /> it 5f'g :. 1w .d eill <br /> Address Address <br /> 1-fl &l a CA 95240 ;6 <br /> Phone No. — 8 4 2 Phone No. <br /> �r <br /> Containers Type <br /> Description of Waste Oud AtityUnits No. T pe 0- Crum <br /> { } ' C-Carton <br /> a Iv] � B_Bag <br /> . <br /> c a l t lata k f4 �El ..Ste-1 Uit h 'PUP1 .6 011 T -Truck <br /> ❑ m ❑• P - Pounds <br /> Y-Yards <br /> ❑ m ❑ O•.Other 1 <br /> I hereby certify that the above named material does not contain free liquid as'}defined by 40 CFR"'Part 250.10 or any applicable <br /> state law, is not a hazardous waste as defined by 40 CFR Part 261 or any applicable state law, has been properly described, <br /> _.classified,and packaged, and is in proper condition for transportation according to app licable'regulations. <br /> e. <br /> f < 1rr .1 .+*S"''. '��, � ',zdS��.n"""A"'yT' •i ' !a f 17 <br /> .:!0' e3tp <br /> Generator Authoriied Agent Name -Signature ' 'r Shipment Date <br /> lej .I <br /> TRANSPORTER <br /> Truck No. r .e4 Phone Na. ; 7ta <br /> Transporter Name lst' atrat�ttzfttr�, i � <br /> Po Driver Name (Print) 62212,,v �e rV <br /> 1898 Park Roni! <br /> Address Vehicle License NoAtate'd' <br /> Vehicle Certification ` <br /> iR <br /> I hereby certify that the above named material was picked_up 1 hereby certify that the above named material was delivered with- <br /> at the generator site listed above. out incident to the destination listed below. i <br /> .:*8t`'.Y ( �"_ tom.,... '� •' �'.,"' 4.'r � .+....f� f f � �,�'/� �. ,+ <br /> ' I..J' 2.. { � �i ,� l'• t" �..MS".a.:.r,�� _ .k "�a y,�fiS�d � �-,�% .f ��'" :C,�• �' <br /> ' Driver Signature Shipment Date Driver Signature • Delivery Date i <br /> ' DESTINATION <br /> Site Name k, <br /> _ _ ' b 4 4 8 .. <br /> Phone No:F <br /> t I <br /> 1143 Z40 Charter 'i aye t�t�e•kta � CA 952026' i <br /> Address i <br /> I " iby certify that the above named material has been accepted and tb:,fhe best of my knowledge the fofegojng is true and accurate. <br /> ( .71 <br /> � <br /> 4 j ! <br /> .Name of Authorized Agent Si natu►® z, <br /> —. '� R_eceipt Dale <br /> •c - ci 1 .� <br />