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NON-HAZARDOUS 1.Generator ID NumberPage 1 of 3.Emergency Response Phone 4.Waste Tracking Number { { <br /> WASTE MANIFEST T RMU T <br /> 1 Q 881 <br /> 5.Generators Name and Mailln Address Generators Site Address(if different than mailing address) <br /> EWRM' 9 <br /> r 82M MGM CA 9MOS 1112 1Z"Odft W rftOWn,CA SUM <br /> Generators Phone: ^' <br /> 6.Transporter 1 Company Name '' U_S.EPA ID Number <br /> ..Lim CAROM4= <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated,Facility Name and Site Address U.S.EPA ID Number <br /> 1 <br /> Iwo W.1j saw CAM20401"D <br /> Facili s Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity WI.Nol. <br /> i.Ix { <br /> ¢ <br /> w <br /> Z 2. <br /> w <br /> (,7 <br /> 3. <br /> 4. <br /> 13.Special Handling Instructions and Additional Information t <br /> 4V VOUM WO3 <br /> fpmod <br /> fi L,' � ti <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 all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generatoes/Offeror's Printedfryped Name r SignatuMonth Day Year <br /> re <br /> 15.International Shipments ❑ •e; <br /> Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> Cr Lu <br /> i6.Transporter Acknowledgment of Receipt of Materials <br /> rr Transporter 1 Printedrfyped Name Signature M nth Day Year <br /> a <br /> u7 <br /> a Transporter 2 Printed(TyfA Name Signature Month Day Year <br /> r- <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Type ❑Residue ❑Partial Re ection ❑Fun He action <br /> ❑Quantity yp 1 j <br /> Manifest Reference Number. <br /> r 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _3 <br /> LL Facility's Phone: <br /> 0 17c Signawre,of Alternate Fachty(ot Gentra m) Mara Day Year <br /> a <br /> Z <br /> 18.Designabed Farifs'p O%ner or Operator:CerE xwion of rec t of mated covered by*a marifest except as r* m 17a <br /> PMtedr ped Nae p i y Signature Mo h Ila Year <br /> KI , ( ,, O— L,- -, <br /> 169-BLC-0 5 119n(Rev io9) TRANSPORTER M <br />