Laserfiche WebLink
NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST t4 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Calitomia Stop SAME <br /> 2224 Manthey Rd <br /> 6tocldon.CA 95206 <br /> Generators Phcn $-1 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> LD Transportation LLC CAR000183152 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddresINSTRAT,INC U.S.EPA ID Number <br /> 1105 AIRPORT RD. I <br /> RI4 VISTA,GA 94571 ��'A- <br /> Faciti 's Phone53a-753-1828 <br /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity Wt.Nol. <br /> ¢ <br /> Drill Cuttings 001 CM 010 Y <br /> 0 <br /> a <br /> ¢ <br /> W <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 13.Special Handling Instruct,ons and Additional Information <br /> Wear Proper Personal Protective Equipment,While Handling <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 respells in proper condition for transport according to applicable international and national governmental regulations. <br /> Generators/ erors Printed(ryped Name Signal Month Day Year <br /> w 3( <br /> 15.Intemalkmal Shipments <br /> ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> Transporter Signature for exports only): Date leaving U.S.: <br /> ¢ 16.Transporter Acknowledgment of Receipt o1 Materials <br /> ui - / Month Day Year <br /> Transporter 1 Printed/Typed Name r <br /> Tj r t <br /> a 1174;rIQ- <br /> z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> cra <br /> r <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑ ❑Full Re Quantity El Residue Partial Rejection Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> to <br /> W <br /> O <br /> r18,D_:gn�aAl'eeacility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> ed/Typed Name Signature . - n \ Month Day Year <br /> M I CHAEL L.3H 1 -t484D l ' �1\J 3 31 is <br /> DESIGNATED FACILITY TO GENERATOR <br /> 169-BLC-0 6 10498(Rev.9/09) <br />