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NONHAZARDOUS i•Generator If]Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracidng Number <br /> WASTE MANIFEST MIA { <br /> 5.Generators Name and Mailing Address !2 E- 73R f+bE-s14674-N <br /> 011E RL i�ERF=L'y'RPAANCE:� <br /> Generator's Site Address(if different than mailing address) <br /> r$04 f Ft lrMX4-1 S'J' r 1'E,i ILit _Ft_�5T <br /> S i 'CX T k')N,CA 115219 <br /> Generator's Phone: 94w+-23?­2789 ' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> E.MffE1OTAENTAL 1_ (�I i`l S, ;f~ CAP.00,321_fEi3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DteSigod edtFaCil ty(J me aSiteLLddrtV <br /> AK: :ES .Nr- U.S.EPA ID Number <br /> iYFUEEwfE:t�>tc?'tL'fJt'dTU AVENU <br /> Facili 's Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No, Type Quantity Wt.Nol, <br /> 1. N?ttHAZARDOUS WASTE L{Grfflir,Vil%TEr)cc <br /> ——_:�� <br /> t� <br /> ,. r <br /> Q { •i.✓�. <br /> Lu <br /> LU 2- NC*1 i-AZARVO S WASTE$tjl_ICi(80ilLi 17 rjfA ra <br /> 3. <br /> 4. <br /> 13. Special Handling Instructions and Additional Information <br /> 90 wlc, F_R0 11N919� 11VEAR AP(;yh0PRir%7E 11—PE ih�V� 1 tjlT�!f1 <br /> 4"S <br /> r <br /> 14.GENERATOR'S CERTIFICATION:I certify the materials described above on this manifest are not subject to federal regulations for reporting proper dsposal of Hazardous Waste. <br /> Generator'sVeror's Printedlryped Name Signature <br /> Month gDay Year <br /> j 15..International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entryleAV. <br /> a <br /> Transporter Signature for exports only): Data leavin U.S.:, <br /> m 16.Transporter Acknowledgment of Receipt of Materials <br /> Lu .�,. <br /> Trans Ker 1 Printed/Typed ed Name <br /> po yp Signator Month Day Year <br /> Cn <br /> Transporter Pdntedfryped Name Signature <br /> x -� / Month Day Year <br /> cccc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> rat Facility's Phone: <br /> 17c.Signature of Attemate Facility(or Generator) Month Day Year <br /> — <br /> z <br /> t� <br /> Cl) <br /> a <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedlryped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.8106) GENERATOR'S/SHIPPER'S INITIAL COPY <br />