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t'1 b <br /> ,NON-HAZARDOUS 1.Generator ID Number 2 Page 1 of 3,Emergency Response Phare 4.Waste Tracking Number <br /> WASTE MANIFEST NOT REQU 1 ffi b 0700883 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Efdnvn Twt-RubW Eggknm ft fli m Ts t-F20"M H ft n) <br /> 2732 BIAM U;rRrM t'ar't UkVno CA 82108 1112E HWdM MY.SOCIMOM Cid <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> n <br /> -- CAROMAMM <br /> 7.Transporter 2 CompanyName fn U.S.EPA ID Number <br /> 8. i alertFacilitfcN a an �AddrressR j U.S.EPA ID Number <br /> Ct�Z�n R �1 NOT MVXJM <br /> FacKii es Phone: v(4 CQ 1� f t i{A <br /> 9.Waste Shipping Name and Description to.Containers 11.Total 12,Unfit <br /> No. Type Ouanttty Wt.Nol. <br /> t. <br /> a NO-t]kLQtMM W (60%. y <br /> Lu <br /> W <br /> z 2. <br /> w <br /> r, <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information <br /> pftgi*. � 'i41 <br /> W ©PPE +. WGVftWVd=MeM pmlest a- 045 <br /> apprn*ndat 24 tmLtr urn )4 <br /> 14.GENERATOR'S/OFFEROR'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 all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generator slOfferoes PrintedlTyped Name Signature Month Day Year <br /> 7 j /I Iar <br /> 15.International Stypmen s <br /> ❑import to U.S. ❑Export from U.S. Port o1 entrylexit: <br /> Transporter S' ture for exports Date leaving U.S.; <br /> cc 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedrfypedSignature Mme. Day Year <br /> O `a 2W(C) <br /> j(5} <br /> aTransporter2PrintedR'yp Name Signature Month Day Year <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> T 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> O 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z ' <br /> 0 <br /> 16.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Pdnted(fyped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) TRANSPORTER#2 <br />