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i <br /> t <br /> I :YGig:UNIVERSAL;ENVIR®NMENTAL "911 NIS <br /> O_ <br /> L <br /> P.O.80X 396,BENICIA,CA 94510,(7D7)747-6699 <br /> NON-HAZARDOUS SPECIAL WASTE MANIFEST <br /> GENERATOR ; <br /> Generator Name Torra C Same <br /> L ` <br /> I <br /> Address '900 �A Victor Rd* Address � <br /> Lodi <br /> Qk 95240 <br /> .. — 5 4 ` 7 2 <br /> Phone Na Phone No. <br /> Containers Type <br /> Description of Waste i' Quantity Units' No. TypeD-Drum <br /> � 1 1 C-Carton <br /> B -Bag <br /> Conna3�6'tmated Soil 14th Fuel � 611I T =Truck <br /> ❑. m ❑ P - Pounds <br /> ' Y-`Yards <br /> O. Other <br /> I hereby certify that the above named material does not contain free liquid as defined by 40 CFR'°P,art 260A or;any ap"pllch'ble:: <br /> state law, is not a hazardous waste as defined by 40 CFH Part 261 or any applicable state law(has been;pi•operly descnbed,`• <br /> classified and packaged, and is in proper condition for transportation according to applicable regulations. <br /> Generator Authorized Agent'Name 5ignatue _ Shipment Date <br /> TRANSPORTER• <br /> Truck No. Phone No. I` `07» 7A77 699 <br /> p <br /> i Transporter Name Driver Driver Namel(Print) " rY�� <br /> 1898 Nrk 110 ad <br /> Address Vehicle License No.IStateLd:9 `,</_ i?�l /'v4>44,'q.. <br /> J <br /> en3'a Vehicle Certification` ^' <br /> 11 . <br /> I hereby certify that the above named material was picked up I hereby certify that the above named material was delivered with- <br /> at the;generator site fisted above. outlincident to the destination listed below. <br /> � •�� r ,rim � <br /> .., I"a ,� .l" ,P "✓; (.� 'e�.a ,w"'C�S.,n:" .� '',d �" 4} �' s�!`r � r.. 3 <br /> Driver signature Shipment Date Drivir..Signature Delrv"Date <br /> DESTINATION l° i <br /> r ti <br /> Site Name Phone Nd. <br /> a <br /> Address <br /> 1145 U1, char e'r ��rayo Stoakte%jID CA 95240 <br /> by certify that the above named material has been accepted and4o the best of my k wledge the foregoing.is true and accurate. <br /> 1 t •.. .�" 4_ �' _ "31 - . "` t i 's ' <br /> w4.,fi.: <br /> Name of Authorized Agent Signature '� <br /> -- _ - - -- i „_� Receipt__ate <br />