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} <br /> �J NON-HAZARDOUS 1 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST NOTREQUIRED 1 ;€SSG 2 3-1'i-M) 0700505 <br /> S.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Sroaftw ww•wi a'. X516 403 W€0.1Y'=Yg+C;IUlb 6a4avt0.VR,IK$;1en, , CA <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.—Tran power 2 Company Name U.S.EPA ID Number <br /> 8.Desi ai Fa" Name an Site ds e. r•�t�:�r�r� U.S.EPA ID Number <br /> €01 BRI&Y Raw ma Ra <br /> wked <br /> Facili 's.Phone: ��"`11'fra` 94W6 M-458- <br /> 3.Waste Shipping Name and Description 10.Containers 11,Total V.Unit <br /> No. Type Quantity W(JVOI. <br /> • 1. <br /> cm <br /> a , <br /> w <br /> z 2 <br /> UJ . <br /> 4.. <br /> 13.Spedal Handling Instructions and Additional Information <br /> PrOW. t: 74011,134-2 <br /> 14.GENERATOR'S/01FEROR'S CERTIFICATION: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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Genera 11 orede , mlF«'�'°arJi .moi Gi>1, 3 Signature Month Day Year <br /> .� 15.International Shi ments <br /> p ❑Import to U.S. ❑aw from U.S. Port of entrylexit: ` <br /> Transporter Sinature for exportsonl Dateleavin U,S.: <br /> ir Lu <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> - a Transporter 1 Priniedlfyped Name Signature Month tDay 1� <br /> Year <br /> IL <br /> , (}_ �. rte.;%'r..... 1,_) fd <br /> a Transporter 2 PO�ted/Tllped Name r Si Jnature %'�✓ Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection <br /> J ❑Fal!Rejection <br /> 17b.Alternate Facility{or Generator} Manifest Reference Number: U.S.EPA ID Number <br /> J <br /> U <br /> w Facility's Phone: <br /> Lu 17c.Signature of Alfemate Facility(or Generator) Month Day Year <br /> z <br /> CS <br /> m <br /> w <br /> Q <br /> 1 � <br /> r� t <br /> t i <br /> 1B.Designated Facility Owner or Op�rator.Certification of receipt of materials covered by the manifest except as noted in Item 17a Ir <br /> Prince Typed Name -- ,. <br /> Signature ( Month Day Year <br /> (' ll`tit i;• f ,�f}rf 1' _ ._.j _r�... __,................. <br /> _... f <br /> 169-BLC O 5.111977(Rev.9/09) ,� TRANSPORTER#1 <br />