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s <br /> OMVERSAL..E'NVIRONMENTAL <br /> P.O.'BOX*996;'BENICIA,CA 94510,(707)747-6699 <br /> NON-HAZARDOUS SPECIAL WASTE MANIFEST k <br /> GENERATORi <br /> Generator Name ° C? €"`' `�nxr�g+tit" a t: Generating Location i Sams <br /> Address' 900 �A Victor Marl.. Address <br /> Lod!, CA, 95240 l <br /> Phone.No. 0 "'- Z14 J7 " T Phone No. <br /> Containers Type <br /> Description of Waste '; Quanti. Emits '. No. T pe d• Drum � <br /> C-Carton" <br /> ❑ 11 <br /> B.. Bag <br /> 4.' <br /> 7 <br /> f lucrzl amt s� sd � , t1if ].. •.. = �, T -Truck <br /> , ❑ ❑❑ ❑ <br /> P -Pounds <br /> Y-Yards <br /> �� s � t �. ❑ ❑❑ ❑ o• Other <br /> I hereby certify that thetaf;ove named•material does not contain free Ilquid as',"defined by-40 CFR Part 260.10 or any applicable <br /> state law, is not a huardO ,S wasteias defined by 40 CFR Part,261 or any applicable state law, has been properly described, <br /> classified and packaged, an As in proper condition for transportation according to applicable regulations. <br /> 77-1 <br /> Generator Authartzed Agent Name `Signature. Shipment Date <br /> .k r <br /> TRANSPORTER <br /> n <br /> Truck"' afr~ r � Phone No. ;7 07 <br /> 7447-660 <br /> .�fx��.�ex:���. 3�x��al�+ ��tltat�tu �.. <br /> Transporter Name Driver Name (Print) <br /> rk <br /> AddressTt 'k"` ; Vehicle License No./State _BenicJ <br /> # 10 <br /> Vehid e Certification <br /> � <br /> I her certify that the above narked material was picked up hereby certify Shat the above na ed material was delivered with- <br /> iF <br /> at the generator site listed,abave. out incident to the destipatiot"listed below. <br /> ' yr ✓e". " th' �`" awP ",w .� _ pry1<51 1 w <br /> 7. <br /> Drtirer`$ignature Shipment Date DrlveFftnature"",4 Delivery Date <br /> [- <br /> DESTINATION if <br /> Site Name, &�d Landfill Phone No: 2 O9 �4 b 4 14, � <br /> t- <br /> Address 1145 14. C%artpr t+uxty, St acktaij, CA 05206 r <br /> I,�_eby certify that the above named material has been accepted and toAhe­t st-iaf�my knowledge the forego ng is true and accurate.71. <br /> �'-,s ?- %� :� L� .,-,,�.� �.. �i" � ..i%�N �'_ ,...—w+ 's'n �. w', �.:.,...•.,.':'r � - � � � tee+ <br /> k Name of Authorized AgentSignature <br /> I <br /> Receipt Date <br /> f <br />