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NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Trac ng Numberer ` <br /> WASTE MANIFEST, Z O !J <br /> 5.Generafol's Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> Gulk Stop Markets,Inc.Alt:Michael Karvelot 3555 West Hammer Lane <br /> 467 Erderpnse Street Stockton,CA USA <br /> Fremont,CA 94536 USA <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> DILLARD ENVIRONMENTAL SERVICES CADWM3433 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.D t amYbt.N �r�d Site Address U.S.EPA ID Number <br /> NVT33001ODCO <br /> Highway 95-12 Mlles South of Beatty <br /> Beatty,NV 89033 <br /> Facilit's Phone: <br /> 800.239-3043 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description No. Type Quantity WWol. <br /> 1.--whazardouswaste Solid(01111 Cuttings DM P <br /> ac <br /> 1y�,0 <br /> ccW <br /> w 2 Non Hazardous a e ofd(Drill uttings Nucdncrete) DM rP^ <br /> 3. <br /> 4. <br /> 13. SJ08 4122i)0Wl�and Addrtlbnallnronnetion <br /> DE <br /> 9(1):PF# 07 OI ;;I g--04'r'3 — QJ+S8�2_, <br /> 9(1):PF# <br /> 14.GENERATOR'SIOFFEROR'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 labeled/placarded,and are in at respects In proper condition for transport according to applicable international and governor al regulations. <br /> Generatofs/Offeroors Pdnteffry -Name�Q Signator Month Day Year <br /> 15.Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of an /exit: <br /> Transporter Signature for exports orgy): Date laavin <br /> cc 16.Transporter Acknowledgment of Receipt of Materiels <br /> 2 TranPdar <br /> ntedfryped Name Signature \ Month Day Ye <br /> y �CA- <br /> Transporter Pdnte yped Name Signature / Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mangeat Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.FPA ID Number <br /> 7 <br /> s <br /> Fadlity's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> zz <br /> 4� <br /> N <br /> W <br /> O <br /> 18.Designated Facility Owner or Operate.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed?yped Names Signature Month Day Year <br /> or <br /> 169-BLC-06 10498(R .9109) DESIGNATED FACILITY TO GENERATOR <br />