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4V wk <br /> r 1601 <br /> NON-HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number p <br /> WASTE MANIFEST T MOUNw'j 0700884 <br /> 5.Generators Name and Mailing Address Generator's Site Address(it different than mailing address) <br /> Evahmn Trw- Tntst-EsmC1m Hy*vjft exam <br /> 7 2 CA SZOR 1112E 03W1Y. CA <br /> Generators Phare: <br /> 6.Transporter 1 Company Name U.S.EPA ID Numbet <br /> 7.Transporter 2 0ompanyame &nbn I hIC U.S.EPA ID Number <br /> 8. si Hated F Na a an Address (VtOqq 11 zon U.S.EPA ID Number <br /> V& 0NOT <br /> !t q QUIPffi <br /> Fadli s Plane: 1K!CU vI�l�1 C ft <br /> 9.Waste Stripping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WI.Nol. <br /> Ir L <br /> W <br /> z 2 <br /> W <br /> 3. <br /> 4, <br /> 13.Special Handling Instructions and Additional Information <br /> wex Wd D PPE ing. or Wumm aru <br /> 24 hMU eMOVIX1Wnr r(M)4 <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fusty and a4curately described above by the propershipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations, <br /> Generalors0feroes Pdntedrryped Name ,, f j Signature # Month Day Year <br /> J 15.International Shipments <br /> I— ❑import to U.S. ❑Export from U.S. Pod of entryleAt: <br /> Transporter Signature far exports on Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Lu <br /> Transporter 1 Primedfryped Name Signature M��o If �DDa,yy Year <br /> JX <br /> a. <br /> dA <br /> a Transporter 2 Printedffyped Name Signature Month Day Year <br /> Cr <br /> r- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space El <br /> Quantity ❑Type El Residue ❑Partial Relection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> U <br /> u4 Faclity's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> t9 <br /> W <br /> t� <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by me manitest except as noted in Item 17a <br /> Pdnt ped Name / Signature Mont Day LYe r <br /> 169-BLC-O 5 11977(Rev.9/09) TRANSPORTER#2 <br />